Providing Sexual and Reproductive Health Advice via SMS in Uganda

In Sub-Saharan Africa, about 1.8 million people became infected with the HIV virus in 2011, with the majority of new cases attributed to unprotected sex. This study tested whether providing sexual health information through SMS messaging could lower rates of risky behavior. Through a partnership with a telecommunications provider, Google, and the Grameen Foundation, a new service was marketed to randomly chosen villages which allowed people to query a database by texting sexual health questions to a phone number. Follow-up quantitative surveys using new methodologies for asking sensitive questions found an increase in self-reported infidelity. Among some men, numbers of reported sexual partners went up, while more women reported abstinence. Qualitative interviews suggest a possible explanation for this gender difference.
Read the full paper here.
Policy Issue:
The rapid adoption of mobile phones in developing countries has created new opportunities for disseminating information to large populations at a low cost. Recently many public health organizations have designed projects that use mobile technology to support health services and health education. In contexts where knowledge about a particular health topic is low, people often lack adequate information to make decisions that will maintain or improve their health. This lack of information can lead them to underestimate the specific health risks they face and engage in risker behavior than they otherwise would have chosen.
In Sub-Saharan Africa, about 1.8 million people became infected with the HIV virus in 2011, with the majority of new cases attributed to unprotected sex. One potential way to reduce the rate of unprotected sex and STI infection could be to improve access to sexual health information. Can providing mobile phone users with sexual and reproductive health information via text message improve their knowledge of safe and unsafe sexual behaviors and ultimately lead to reductions in risky sexual behavior?
Context of the Evaluation:
Uganda has several features that make it a prime candidate for a technological intervention focused on sexual health. HIV prevalence is high: UNAIDS estimated HIV prevalence to be 6.5 percent among adults aged 15–49 in 2009. In addition, UNAIDS reports that knowledge regarding sexual health and HIV/AIDS is low and risky sexual practices, like low condom use, are prevalent. Misconceptions about sexual and reproductive health are widespread and access to reliable information or sexual education is limited. At the same time, three quarters of the adult population are literate and there has been a rapid increase in mobile phone ownership. In 2002, less than 3 percent of the population owned a mobile phone, but by 2010 over one third of the Ugandan population owned one.
Description of Intervention: 
Researchers conducted a randomized evaluation to test the impact of improving access to sexual and reproductive health information via SMS message service on health knowledge, attitudes, and risky sexual behavior. From a sample of 60 villages in Masaka, Mpigi, Mityana, and Mubende districts in Central Uganda, researchers randomly assigned villages to receive encouragement to use a new mobile phone-based sexual and reproductive health information service, or to serve as part of the comparison group.
The sexual and reproductive health information service, called 6001 (the phone number to which users send a text message), was developed by, Google, Grameen Foundation, and MTN, Uganda’s largest mobile phone service provider. It allows mobile phone users to text questions on sexual and reproductive health to a server and to receive pre-prepared advice from a database of responses about HIV/AIDS, other STIs, maternal and neonatal health, body changes and sexuality, and family planning. The database has approximately 500 unique messages. Messages are about 500 characters long, consist of factual information presented in simple language, and often include an encouragement to use condoms or get tested for HIV. For example, in response to the question, “What does HIV reinfection mean?” users received the following SMS message:
“There are different types (strains) of HIV/AIDS so even if you are already infected you can catch another type of the virus which can make you more sick. HIV reinfection is when somebody who already has HIV gets the virus again by having sex without a condom with an infected person or if infected fluid gets into their body through cuts/unsterilized sharp instruments. Use condoms EVERY TIME to protect yourself + others.”
Users can send queries in English or Luganda and receive responses in the respective language. They can also send in the name of a particular health issue and their location to receive contact and service information for the nearest health facilities.
In villages that received encouragement to use the 6001 service, marketing teams visited trading centers three to six times in August 2009, depending on population size, and each time spent a full day promoting the service through demonstrations and flyers and posters in both English and Luganda. Comparison villages did not receive this extra marketing encouragement, but they could still use the 6001 service. 
One year after conducting the baseline survey, researchers conducted a follow up survey with over 2,400 respondents in treatment and comparison villages in February 2010. They complemented the quantitative data with qualitative data from eight focus groups and 39 in-depth interviews that covered perceptions of the 6001 service, usage behavior, and perceived sexual health knowledge, behavior, and attitude changes. 
To get more truthful answers on sensitive topics like condom use and number of sexual partners, researchers used a survey technique called list randomization. List randomization enables respondents to report on sensitive behavior without allowing the researcher to identify their individual response. Half the participants are randomly selected to receive a short list of activities and asked how many they have engaged in, but they do not have to state which ones. The other respondents see the same list of activities, but a key sensitive activity of interest to researchers, like condom use, is added. The difference in the average number of activities done in the two groups lets the researchers estimate the proportion of respondents who engage in the sensitive behavior. In addition, differences in the difference between answers elicited through direct and indirect methods allow researchers to estimate whether the intervention had an impact on social desirability bias. 
Results and Policy Lessons:
Impact on take-up and use: Forty percent of respondents living in villages that received the marketing encouragement sent in at least one SMS message to the 6001 service in the following year, relative to 7 percent in comparison villages. Between December 2009 and April 2010, the average total number of text messages sent per day from all phones associated with treatment villages was 4.0, compared to an average of 1.5 messages per day from all phones associated with comparison villages. While respondents in treatment villages continued to use 6001 significantly more than respondents in comparison villages, use in treatment villages dropped dramatically after the marketing firm stopped promoting the service in trading centers. In qualitative interviews, respondents in treatment villages said they would have liked to be reminded about the existence of the service for a longer time period. Overall, 6001 users were more likely to be male, young, married, to own a personal phone, and have slightly higher education levels.
Impact on knowledge and risky sexual behavior: Increased access to information through the 6001 service did not increase sexual and reproductive health knowledge and led to an increase in self-reported promiscuity for some and abstinence for others. Researchers found no significant increases in knowledge about possible modes of HIV transmission or effective contraception methods and use in treatment villages relative to comparison villages, but found a higher incidence of risky sexual behavior and increased self-reported promiscuity, particularly among men. They also found increased abstinence as well, particularly among women, who were 6.3 percentage points less likely to have had sex in the past year. Self-reported infidelity (defined as reporting having been unfaithful to one’s current partner in the past three months) increased from 12 percent to 27 percent, as did the number of sexual partners for men. Overall, individuals in treatment villages did perceive their sexual behavior as being riskier, which could be an indication that 6001 led them to more accurately assess the health risks they face. However this change could also be the result of their riskier self-reported behaviors and possibly a desire to answer the surveyor in a particular way. 
Qualitative interviews shed light on the possible reasons why the 6001 service had this mixed impact. For information provision to result in behavior change and improved health outcomes, people must use the service, obtain useful information from it, and be able to act on it. Since risky sexual behavior inherently involves more than one person, respondents may not have been able to stop engaging in risky practices due to the power balance in their relationship. Both male and female respondents reported that married women learned from the service about the risks associated with having an unfaithful partner and as a result insisted that their husbands be faithful and go for STI testing with them. According to qualitative reports some husbands complied while others did not, leading women to deny them sex and men to seek it from other partners instead. 
The results of this study suggest that introducing an information technology that is left to individuals to self-direct their use may not be enough to lead to the desired behavior change. Since sexual behavior change requires two people to agree to adopt less risky behaviors, easing access to health information may not be enough to convince both partners to adopt less risky behaviors, and can potentially directly or indirectly lead them to make riskier choices.
Julian Jamison, Dean Karlan

An Entrepreneurial Model of Community Health Delivery in Uganda

Despite a substantial decline in child mortality in recent years, millions of children still die from preventable diseases every year. In this study in rural Uganda, researchers evaluate the impact of a micro-franchise model, which incentivizes door-to-door health workers, on under-five mortality rates.

Policy Issue:

In a world with underserved populations who have inadequate access to basic health services, an increasingly common approach to reaching these populations is community health worker programs. These programs aim to improve health outcomes among groups that have traditionally lacked access to adequate health care by recruiting community members to serve as connectors between healthcare consumers and providers.2 However, evidence indicates that there are mixed evidence of this approach in reducing child mortality.3 Weak incentives for community health workers to deliver timely and appropriate services are believed to limit the effectiveness of these programs.4 A potential solution may be financially sustainable delivery models where the health workers earn a margin on product sales and small performance-based incentives. This study in Uganda assesses the impact of such a non-profit entrepreneurial model of community health delivery.

Context of the Evaluation:

Although infant and under-five deaths in Uganda have declined substantially is recent years, 69 out of 1,000 children in the country still die before age five.5 To reach an international target of reducing the under-five mortality rate by two thirds, Uganda will need to sustain a rapid rate of progress. 6

Living Goods, a U.S.-based non-governmental organization, created Living Goods Community Health Promoters (CHPs), with the aim of improving access to and adoption of simple, proven health interventions in rural and peri-urban areas in Uganda. The program is carried out in partnership with the Bangladesh-based non-profit BRAC. CHPs are women trained to operate micro-franchises, which sell a line of health products below market price, door-to-door to households in their communities. Apart from providing health education and access to basic health products at low costs, this model aims to create sustainable livelihoods for the CHPs, who operate with financial incentives to meet household demand and receive small performance-based incentives for home visits and referrals.

Details of the Intervention:

Researchers carried out a randomized evaluation to evaluate the impact of the Living Goods and BRAC Community Health Promoters (CHP) program on under-five mortality rate in rural Uganda. Researchers randomly assigned 214 villages across 10 districts to either the treatment group, which received the CHP program, or the comparison group, which did not receive the program.

Over a three-year period, CHPs conducted home visits in the 115 villages in the treatment group, educating households on essential health behaviors and offering preventive and curative health products for sale at 20-30 percent below prevailing retail prices. Prevention products included long-lasting insecticide treated mosquito nets, vitamins, and water purification tablets. Curative treatments included antibiotics, antimalarial drugs, oral rehydration salts, and zinc. Additionally, in order to incentivize the CHPs to provide maternal, newborn, and child health services, Living Goods pay CHPs US$0.20 for every home visit within 48 hours of delivery.

Ninety-nine villages did not receive the program and served as a comparison group. On average, around 38 households were surveyed per village at the end of 2013, for a total sample size of approximately 8,100 households.IPA conducted the final household survey in 2013, approximately three years of Community Health Promoters operating in the treatment villages. The primary study outcome is under-five child mortality rate over the period 2011-2013.

[Note: IPA only implemented final data collection, in 2013.

Results and Policy Lessons:

Results forthcoming.


[1] UNICEF. Millennium Development Goals: Child Mortality.

[2] Witmer, Anne, Sarena D. Seifer, Leonard Finocchio, Jodi Leslie, and Edward H. O'Neil. "Community health workers: integral members of the health care work force." American Journal of Public Health 85, no. 8_Pt_1 (1995): 1055-1058.

[3] Lewin, Simon, Susan Munabi-Babigumira, Claire Glenton, Karen Daniels, Xavier Bosch-Capblanch, Brian E. van Wyk, Jan Odgaard-Jensen et al. “Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases.” Cochrane Database Syst Rev 3 (2010).

[4]“Community and Formal Health System Support for Enhanced Community Health Worker Performance: A U.S. Government Evidence Summit” USAID Final Report 2012.

[6] Millennium Development Goals Report 2013: Drivers of MDG Progress in Uganda and the Implications for the Post-2015 Development Agenda.

Enterprises for Ultra-poor Women After War: The WINGS Program in Northern Uganda

What’s holding back impoverished women? Can small grants programs help the most vulnerable women develop sustainable livelihoods? Do employment and poverty relief empower them and improve their lives? This evaluation assessed the impact of a program that gave cash grants and basic business skills training to the poorest and most excluded women in post-war northern Uganda. The program led to dramatic increases in business and reductions in poverty. Despite these economic gains, however, there was little change in social integration, physical or mental health, or empowerment.

Find a policy note with more detail here and a full in-depth policy report here (PDFs)
Policy Issue:
According to one view, women have the ability to run businesses and make profits, but they are held back by too few assets, too little access to loans, too few skills, and a host of social barriers. What happens, then, when these economic barriers are removed? This study evaluates a program that gives cash, business skills training, and ongoing advising to some of the poorest women in the world, in northern Uganda, to understand its effect on new business development and poverty.
Another view holds that for women, with economic success comes empowerment - more independence, more decision-making power in the household, and the freedom to leave abusive relationships. This study also tests whether an entrepreneurship program that reduces poverty also empowers the women in other aspects of life.
Evaluation Context:
The study takes place in northern Uganda, which is emerging from twenty years of conflict and displacement. Young women and girls in particular suffered economically and educationally from the war. The women who participated in this study were displaced from their homes and lands for years, and are returning and rebuilding a life. Thus this study can inform strategies for post-war reconstruction for women and for the society in general.
In 2007, the NGO AVSI Uganda and two of the IPA Investigators surveyed more than 600 young females aged 14 to 35 affected by the conflict in northern Uganda, including more than 200 women formerly abducted by an armed group. The evidence from the survey, along with program experience among NGOs in northern Uganda, suggests that the development of new economic opportunities and building social capital will be crucial ingredients in reducing poverty and improving the health, education and psychosocial well-being of youth, especially young women. 
AVSI and the investigators worked together to design a program that would relieve the most serious economic constraints on women: The Women’s Income Generating Support (WINGS) program.
Description of the Intervention:
AVSI identified the 15 poorest and most vulnerable women in 120 villages that they wanted to support - 1800 in all. To each, they delivered WINGS’ three core components:
1.       Four days of business skills training (BST)
2.       An individual start-up grant of roughly $150
3.       Regular follow-up by trained community workers
Additional optional components of the program include group formation, training, and self-support; and spousal inclusion, training, and support. Based on records provided by AVSI, the total cost of the intervention is estimated at approximately $688 per person.
Evaluation Design:
The evaluation combined a randomized design with qualitative data collection. AVSI could help no more than 900 people in 60 villages at first - serving 900 already required them to triple their usual capacity. Thus AVSI and IPA held public lotteries with village leaders. 60 villages were selected to participate immediately, while the remaining 60 participated 18 months later. This design allowed for assessing 18-month impacts by comparing women in participating villages to those just about to receive the program.
Economically, the program was transformative. For example:
Cash Earnings: Earnings nearly doubled. For the average WINGS beneficiary, monthly cash income increased by UGX 16,211 to 32,692 UGX, a 98% increase over controls. In absolute terms, an increase of UGX 16,211 does not seem large (about $6.50 a month at market exchange rates). However, relative to the average income in the control group, UGX 16,481 ($6.60), it is huge. 
Consumption, Assets, and Savings: Participants in the WINGS program had a 33% increase in household spending, a value of UGX 11,741 ($4.72). There is also an increase in wealth, and the results imply that WINGS clients substantially increase their durable assets. Savings for program beneficiaries tripled on average, going from UGX 40,740 ($16.36) to UGX 169,862 ($68.22). 
These economic gains, however, were not matched by gains in health or empowerment. In fact, there was almost no effect on non-economic measures. For instance:
Physical and mental health: There was no significant difference in psychological distress. Women in both the program and comparison groups reported a reduction in psychological distress over time, which is not surprising because the overall quality of life in northern Uganda improved after war and displacement. Women in the WINGS group did not improve more or faster, however. If anything, they were sick about a half a day more in the previous month. 
Child investments: Woman are often targeted by anti-poverty programs because they are believed to be more likely than men to use the profits to benefit the household, especially children’s education and health. Women in the program spent slightly more on children’s health and education, but there was no corresponding improvement in children’s health status or school enrollment, at least after 18 months.
Empowerment: The conventional wisdom also assumes that lending to women will enhance their status in the household. Data from this study, however, showed no evidence of resulting empowerment for women in household decision-making, independence, gender attitudes, or rates of intimate partner violence. This pattern has been seen before, and is often referred to as the “impact-paradox.” 
Overall, the WINGS program impacted women’s economic standing significantly, but the data show that translating these gains into improvements in psychological health, physical health, or empowerment is more complex.
For more, you can read a first person account of the project on the Freakonomics Blog.

Northern Uganda Social Action Fund – Youth Opportunities Program

Youth unemployment is a persistent problem in the developing world, particularly in post-conflict settings, posing both economic and security issues. In growing, stable economies such as Uganda, what holds back youth from reaching their potential?  One theory suggests that youth unemployment is due primarily to the lack of sufficient capital to support entrepreneurship. If this is true, cash transfers or cheap credit could lead to a burst of self-employment. Evidence from other areas, such as studies on microcredit, suggests that alleviating these constraints with loans has little effect on earnings. In Northern Uganda, which is returning to peace after twenty years of war, the government’s Youth Opportunities Program offered cash transfers to groups of youth to increase employment and reduce conflict. Follow-up surveys two and four years later found a shift from agricultural work towards skilled trades and strong increases in income. Women in particular benefited from the cash transfers, with incomes of those in the program 84% higher than women who were not. There were no differences, however, in social outcomes such as community participation, aggression, and social cohesion.

See the full paper herea policy note for the World Bank here, and Chris Blattman’s blog discussion here.

Policy Question:
In developing countries, high unemployment - particularly among youth - is a pressing concern. Jobs, particularly higher-skilled labor and productive small enterprise, provide incomes and reduce poverty. For governments, transitioning from an economy based on small-scale agriculture to one based on entrepreneurship and production is critical for long-term growth. Employment is also seen as important for building social stability and political engagement in communities uprooted by long-term conflict.
One form of intervention offers cash in the hopes that youth will invest it in the training and assets to learn a trade or form a business. In the development community, anxiety persists over whether this is an effective approach: will youth with little or no financial or business training be able to direct the money towards successful long-term entrepreneurship?  Previous research also raises questions about the ability of women in particular to invest aid into increasing lifetime earnings, given occupational constraints and pressure to share windfalls.1
Uganda’s largest employment program sought to test if an intervention as simple as giving cash could help accomplish the country’s long-term economic and social goals for its youth.
Context of the Evaluation:
Twenty years of insurgency, instability and conflict led to high rates of poverty and unemployment in northern Uganda, but by 2005 a measure of peace and stability had returned to the region. The centerpiece of the post-conflict recovery plan was a decentralized development program, the Northern Uganda Social Action Fund (NUSAF). In 2006, to stimulate employment growth through self-employment, the government launched a new NUSAF component: the Youth Opportunities Program (YOP), which provided cash transfers to groups of young adults with the goal of encouraging trade-based self-employment. 
Description of the Intervention:
The YOP intervention had two official aims: to raise youth incomes and employment and to improve community reconciliation and reduce conflict. The program, targeted at youth from ages 16 to 35, required young adults from the same town or village to organize into groups and submit a proposal for a cash transfer to pay for: (i) fees at a local technical or vocational training institute of their choosing, and (ii) tools and materials for practicing a craft.
The average applicant group had 22 members. Group cash transfers averaged nearly UGX 12.8 million (US$7,108), and varied by both group size and group request. The average transfer size per member was UGX 673,026 (US$374) – more than 20 times the average monthly income of the youth at the time of the baseline survey.
Due to vast oversubscription, the 535 eligible groups were selected at random, using a lottery, to either receive the YOP program or be part of the comparison group. A baseline survey was conducted with 2601 individuals in 2008, and 87 percent were successfully followed and interviewed in the endline surveys two and four years later.
Results and Policy Lessons:
Overall, the program seemed to have strong economic effects. Four years later, beneficiaries of the YOP program had 41% higher income and were 65% more likely to practice a skilled trade, such as carpentry, metalworking, tailoring, or hairstyling. Hours worked were 17% higher, nearly entirely accounted for by these new professions – while most still farmed part-time, hours spent in agriculture were not different. They were also 40% more likely to keep records, register their business, and pay taxes.
Within the sample, gains were highest for those who had the highest initial credit constraints, those with fewest initial assets and access to loans. The effects were particularly strong for women. Women who received the cash grants four years later had 84% higher incomes than women who did not, while men were earning 31% more than their counterparts in the comparison group. This gender difference may reflect particular capital constraints faced by women.
While employment programs including this one are often implemented by governments with the aim of reducing social instability or promoting cohesion, the data show no evidence for impacts in these domains. After four years there were no measurable differences in cohesion, aggression, or community and political participation between participants in the YOP program and those in the comparison group.
Overall, the data show that the poor used the money effectively; investing in training and tools needed to start businesses and experienced a significant growth in income, even after four years. Even though impacts in social domains were negligible, the economic outcomes show the potential of alleviating capital constraints for spurring economic growth among the poor. 
Read the full paper here.
A midterm policy report here and policy note by the World Bank here were based on the initial 2-year follow up data.
[1] Fafchamps, M., McKenzie, D., Quinn, S., Woodruff, C., 2011. When is capital enough to get female microenterprises growing? Evidence from a randomized experiment in Ghana. Unpublished working paper.

Pricing Health Products in Northern Uganda

Previous research suggests that charging even very small user fees sharply limits access to preventive health care, such as bed nets or home water purification. While distributing health products for free in low-income countries is common, it is unclear whether this is the best practice for all products. In northern Uganda, researchers found that free distribution of three health products led to lower demand for the same products when they were later offered for sale, highlighting the importance of product characteristics in determining pricing policy.

Policy Issue:

While distributing health products for free in low-income countries is common, it is unclear whether this is the best practice for all products. Some practitioners argue that free distribution of life-saving products is a moral imperative, while others argue that free distribution actually makes consumers less likely to value and use certain health products.  

Lower prices and “free trial” periods increase demand for certain products while also giving consumers the opportunity to learn about the product’s effectiveness. Depending on prior beliefs about the value of the product, this learning effect can either increase or decrease subsequent demand. At the same time, lower initial prices may also serve as a reference point or “anchor” for the customer, which could lower subsequent demand. This research investigated how product learning and price anchoring affects future demand for health products.

Context of the Evaluation:

This study took place in the Gulu District of northern Uganda, close to the borders of Sudan and the Democratic Republic of Congo. The district is remote and very rural, with about 95 percent of the population engaging in crop production. The Gulu District was destabilized by an insurgency from 1987 until 2006. In the wake of the insurgency, the area received a large amount of NGO and government attention.Compared to other regions in Uganda, Gulu District has experienced a relatively high amount free or heavily-subsidized distributions of health goods. Researchers believe this setting provides a good testing ground for measuring the effect of past prices on current demand.

Details of the Intervention:

Researchers partnered with two Ugandan organizations[1] to design a field experiment in northern Uganda where health products were distributed door-to-door either for free or for sale at market prices. The evaluation took place among 3,884 households in 120 villages in Gulu District.

Marketers offered 3 different products: a) Panadol, a pain reliever widely known to consumers; b) Elyzole, a deworming drug that was moderately well-known and but had unpleasant side effects; and c) Zinkid, an improved treatment for childhood diarrhea that was largely unknown but worked well and did not have unpleasant side effects. By offering three different products with varying degrees of familiarity, researchers were able to specifically investigate whether product learning plays a role in future demand.

Marketers visited each household twice. During the first visit, marketers from either a for-profit or non-profit company offered households one of three products either for free or for sale at lower than market prices. Marketers from a different for-profit company visited the households again approximately 10 weeks later. Three-fourths of these households were offered the same product they were offered the first time, but for sale at market prices. The other quarter of households were offered a different water purification product to assess any potential demand effects for other products.

Results and Policy Lessons:

Overall demand for the three products was lower at market prices if the household had previously received the product for free. Relative to households who had previously bought the product at full price, households who received the product for free were 10 percentage points less likely to pay for the product later. Households’ qualitative responses also support this conclusion: those who received free distribution were more likely to report that they did not want to purchase the product because they or someone in their community had received it for free in the past.

The overall results were driven by large drops in demand for Panadol and Elyzole, both very familiar products. Demand for Panadol was 11.6 percentage points (13.5 percent) lower and demand for Elyzole was 11.8 percentage points lower (30.4 percent). Demand was not significantly lower for the less familiar product Zinkid, suggesting that free distributions or subsidies may not have an effect on demand for new products just being introduced. In other words, for new, less familiar products the learning effect may counterbalance the price anchoring effect.

The relative drop in demand following free distributions was the same whether the product was offered by a for-profit entity or an NGO. There was also no effect of having received a product for free on the demand for the different water purification product, suggesting that the lower demand, or anchoring effect, persists only for the same or similar products. In sum, while lower prices today can dampen future demand by setting low price reference points, opportunities to learn the value of a new product may counteract this effect.

[1] A large Kampala-based NGO focused on the distribution and promotion of health products and a Kampala-based pharmaceutical company that imports, distributes and markets medicines and other products for sale throughout Uganda.

Taxation and Government Accountability in Uganda

For democracies to function well, citizens need to hold leaders accountable, yet in many African nations demand for accountability appears low. This research tests the theory that because people are loss averse, taxation pushes citizens to demand more from their leaders. In games that mimicked real life choices, “taxed” participants were 13 percent more likely on average to punish leaders than those who were not taxed, providing evidence that taxation induces citizens to demand higher levels of accountability from government leaders.

Policy Issue:

Many African countries still suffer from poor governance and corruption despite substantial efforts over the last decades to build functioning, democratic institutions. In many countries citizens’ demand for governmental accountability appears low, even though government mismanagement and corruption is detrimental to the wellbeing of citizens. However, little evidence exists on what makes citizens demand more from their governments. This research examines the role of taxation in increasing citizens’ demands for accountability. In contrast to previous work on taxation and accountability, this research provides evidence on whether taxation drives individuals to demand accountability from their leaders for non-economic, behavioral reasons. If citizens expect taxation to produce an overall gain, such as in services, benefits, or good leadership, the theory is that taxed citizens will perceive corruption as a producing a bigger loss than untaxed citizens. In turn, due to loss aversion, taxed citizens may be more willing to engage in costly actions like protesting or voting against corrupt leaders than untaxed citizens.

Context of the Evaluation:

While overall tax revenues in Uganda have increased in recent years, direct taxation of poor citizens has actually decreased, with tax cuts often timed to win support among key electoral groups. The result is that poor individuals pay few direct taxes, and while even basic public services are difficult to obtain, there is little concrete outrage about poor governance. A common view among local political leaders, civil society organizations, and academics is that tax cuts have removed a critical link between citizens and government making citizens more disengaged from the political process.

This study was conducted in three low-income neighborhoods of Kampala, Uganda in 2012 and 2013. Kampala has seen significant political mobilization in recent years and its urban citizens have higher exposure to formal taxes than rural citizens. The population in this urban setting was therefore ideal for evaluating the norms and expectations surrounding taxation and accountability.

Details of the Intervention:

To test the theory that taxed citizens are more willing to punish poor performance by government leaders than untaxed citizens, even without any economic incentives to do so, the researcher designed laboratory experiments in which a “citizen” had to decide whether to pay to punish the “leader” based on how the Leader allocated a group fund. By varying whether this group fund came from a tax on the citizens or in the form of an outside “grant,” the researcher was able to compare how participants behaved in the different contexts.  

In the Tax Game, the citizen was given a “wage” of 1,000 Ugandan Shillings (UGX); half of this was then taxed, doubled, and given to the leader as the 1,000 UGX group fund. In the Grant Game, the citizen received wages of 500 UGX, and 1,000 UGX was given to the leader as a non-earned group fund. In both games the leader then decided how to allocate the 1,000 UGX and, after observing the leader’s decision, the citizen could fine the leader 400 UGX by paying a fee of 100 UGX.

The study was run using a sample of 371 respondents over 18 sessions. For each session, IPA recruited volunteers from different neighborhoods in Kampala. Each participant was randomly assigned to a role (leader or citizen) and anonymously paired with others for the games. Each participant played either the Tax or Grant game then took a short survey.

Researchers hypothesized that citizens would be more likely to punish leader in the Tax Game than the Grant Game. In particular, the minimum acceptable share of the group fund that citizens would accept without punishing was expected to be higher among taxed citizens.

A second set of games was used to differentiate the proposed loss-aversion mechanism from alternatives, such as a stricter fairness norm. The new games were identical except that a third-party observer, rather than the citizen, could decide to pay to fine the leader if she disapproved of the allocation; this observer was not taxed and had no stake in the group fund. If taxation increases punishment because a different societal fairness norm applies to tax funds, the third-party observer should be more likely to punish when he sees the citizen being taxed. If loss aversion is the mechanism, the effect of taxation should disappear, as the observer has not been taxed and suffered a loss.

Results and Policy Lessons:

Citizens were significantly more likely to punish the leader in the game when they were taxed. On average the minimum acceptable share of the group fund was 13 percent higher among taxed citizens overall, and 30 percent higher among adult, wage-earning men; the subgroup who has the most exposure to taxation in Uganda.  The results from the second set of experiments provide evidence that the treatment effect is due to loss aversion, rather than stricter societal fairness norms: a third-party observer was no more likely to punish the leader when he saw a citizen being taxed.

Together, the results suggest that taxation may provide a self-sustaining way to increase citizens’ demands on government. It also suggests that donors should consider the role of formal taxation, as well as more informal community contributions, when designing development interventions. Adding community contributions to external aid programs could give beneficiaries more ownership over projects and, this project suggests, make them more likely to hold local leaders accountable for how development funds are spent. However, further research is needed to test the conditions under which such a program would work.

Lucy Martin

Budget Transparency and Political Oversight in Uganda

Many local government officials operate in settings with weak institutions and limited oversight. This study in Uganda evaluates the impact on accountability and quality of public services of putting budget information into the hands of local councilors and opinion leaders.

Policy Issue:

Local governments are crucial for public service provision. They collect taxes, draw up budgets, select contractors, report information to the central government, and manage resource flows. The recent wave of decentralization in developing countries has rendered local governments’ role all the more important. Yet many local government officials operate in settings with weak institutions and limited oversight. Increased budget transparency may result in improved accountability and quality of public services. If so, it is important to establish to whom budget information should be targeted.

This project departs from most empirical research on accountability by focusing explicitly on strengthening the oversight function of local elected representatives over their bureaucratic counterparts.

Context of the Evaluation:

Uganda, like many developing countries, suffers from poor quality basic service provision and weak mechanisms for accountability at the local level.  Uganda has a relatively strong track record in budget transparency, and is ranked second in Africa in the Open Budget Index.  However, these efforts have not been systematic, and it is unclear to which extent they have improved accountability. Due to a 2010 reform, the Ministry of Finance receives detailed project-by-project reports on budget allocations and alleged quarterly expenditures from local governments via an output based digital budget reporting tool. However, local stakeholders, including elected representatives whose mandate it is to monitor service provision, are largely unaware of this information.

To help address this problem, the Ugandan Ministry of Finance, ACODE, ODI, and IPA are launching a Budget Transparency Initiative to make department, project- and location-specific budget information available to politicians, opinion leaders, and the public; and to mobilize them to monitor and provide feedback on the spending and services provided by government institutions.

Details of the Intervention:

This study evaluates the impact on accountability and quality of public services of putting budget information into the hands of local councilors and opinion leaders.

The researcher will assess the impacts of different variations of the intervention among 256 study subcounties in 28 districts. The subcounties are randomly assigned to either (a) have councilors receive information on budget allocations and expenditures, in combination with a day-long training on how to interpret and use it, (b) have both councilors and local opinion leaders receive this information and training, or (c) receive no intervention (the status quo). The reason behind designing the second treatment arm is to enable elite constituents to demand that their political representatives use the budget information to monitor service delivery.

Councilors and local opinion leaders are receiving budget information in print-outs and through a toll-free hotline. The information is also available on an interactive website.

IPA will conduct the first follow-up survey 10 months after the study begins to assess the intervention’s impact on local politicians’ and opinion leaders’ knowledge of budget allocations and rights and responsibilities, their monitoring effort exerted by them, and dynamics in local councils. In late 2015, IPA will conduct a second follow-up survey to assess whether the intervention resulted in improved service delivery.

Results and Policy Lessons:

Project ongoing; results forthcoming


Expanding Access to Formal Savings Accounts in Malawi, Uganda, Chile, and the Philippines

Policy Issue:

Expanding financial services to reach the poorest of the poor helps to broaden their savings and investment options. Yet the vast majority of people in the developing world remain unbanked [1].  In the absence of formal savings products, many in the developing world depend on costly devices like "susus", agents who charge a fee to collect money for secure keeping, or illiquid devices such as rotating savings and credit associations (ROSCAs), groups that pool members’ regular contributions for lump-sum distribution. A majority of rural households store cash at home, “under the mattress” [2], where it is prone to loss, theft, and the demands of neighbors and kin.

Early experimental evidence from Kenya suggests that small business owners can benefit from access to a savings account in a formal bank [3].  By understanding the channels through which savings accounts might impact the lives of poor households, financial institutions—and the products they offer—can be better poised to serve this vulnerable population. 

Context of the Evaluation:

This study is ongoing in three countries: Malawi, Uganda, Chile. We are currently exploring options to add a study site in the Philippines. The aim is to understand the causes and consequences of the lack of access to banking services in a variety of contexts.

Malawi: Malawi’s population is largely rural, with agriculture supporting over 85 percent of the population [4].  A 2009 study found that 55 percent of Malawians do not have access to any type of financial institution, formal or informal; furthermore, only 19 percent of the overall population uses a formal bank [2].  In Malawi, the study is being conducted in the Southern Region, which has lower than average levels of bank usage and financial inclusion [2].

Uganda:A 2006 study found that 62 percent of Ugandans do not have access to any type of financial institution and only 16 percent of the population uses a commercial bank [2]. Total savings remains low: from 1999-2009, Uganda's gross domestic savings averaged 9.3 percent, compared to 21 percent worldwide and 12 percent for the least developed countries [3]. In Uganda, the study is being conducted across several districts in the southwest of the country.

Chile:Although Chile boasts an upper-middle-income economy, such prosperity is not universally shared.  In 2009, Region IX – the target region for the study – reported the highest incidence of poverty in the country at 27.1%, nearly double the national average [3].  And although Chile has a vibrant financial sector, an IPA-led pilot exercise in the target region revealed that 33% of the population does not use a savings account.

Philippines:The Philippines has reached a medium level of deposit account usage, with around 50 accounts per 100 people in 2009.  (Globally, there are more savings accounts than people.) [1] While this is to be celebrated, financial inclusion for rural populations has lagged, and 37% of municipalities did not have access to banking services in that year [7].  Recently, however, the mobile money sector has developed, enabling anyone with a mobile phone to conduct basic transactions.  Mobile banking services have great potential to provide access to the rural poor in this context.

To evaluate the impact of access to a formal savings product, the researchers have partnered with a commercial bank or credit union at each site.    

Description of Intervention:

In each site, IPA identified a partnering financial institution and selected rural areas in which the partnering institution is operating. A probabilistic sampling strategy was then used to enroll into the study a representative sample of unbanked households in those areas.  Upon enrollment and completion of a baseline survey, study households were randomly assigned to either a treatment or comparison group. Those assigned to the treatment group received a voucher enabling them to open an account, at no cost to themselves, with the local branch of the partner institution. They also received procedural assistance with account opening. Take-up of the account offer varied from 20% in Chile to 78% in Malawi.

Follow-up surveys at 6-, 12- and 18-month will be used to estimate the impacts on a range of household activities, including agricultural and business practices, expenditures, household income, response to shocks, and savings and credit practices.Qualitative data will be collected to understand the mechanisms through which access to a bank account affected (or not) the study participants.

Results and Policy Lessons:

Results forthcoming. 


1. CGAP. 2009. Financial Access 2009: Measuring Access to Financial Services around the World.  World Bank Group.

2. FinScope Malawi funded by the UK’s Department for International Development (DFID).  Demand Side Study of Financial Inclusion in Malawi.  2008.

3. Dupas, Pascaline and Jon Robinson.  2009.  Savings Constraints and Microenterprise Development: Evidence from a Field Experiment in Kenya.  NBER: Working Paper 14693.

4.  Reserve Bank of Malawi.  2008.  The Malawi Economic and It’s [sic] Banking System.

5.  FinScope Uganda. 2007. Results of a National Survey on Access to Financial Services in Uganda. Final Report. August.

6.  World Bank. 2010. World Development Indicators 2010 [Online Database]. Washington, DC: The World Bank.

7. Jimenez, Eduardo C. 2010. Financial Access: An Essential Condition. Presentation at the OECD-Banque du Liban Conference on Financial Education.

Building Market Linkages for Smallholder Farmers in Uganda

Prices of staple foods like maize, beans, and rice vary substantially in Sub-Saharan Africa, depending on the season, country, and region. Addressing the imbalance in food supply and increasing farmer income may require a multi-pronged approach that tackles multiple barriers at once. Researchers will evaluate the impact of contract farming services and a mobile technology-enhanced trader alerts system on food markets across Uganda.

Policy Issue:

Prices of staple foods like maize, beans, and rice vary substantially in Sub-Saharan Africa, depending on the season, country, and region. Some countries face food shortages when there is ample supply in the country as a whole, and the same is often true on a regional level.1 The inability of markets to efficiently move food from surplus to deficit regions has a major effect on both farmer incomes and food security. Seasonally, farming families tend to sell when prices are low in the months following the harvest, and buy when prices are high in the months preceding the harvest. Within countries, some fertile and rainy regions experience a food surplus while other regions are chronically in crisis. This imbalance in food supply is often attributed to poor roads and infrastructure, as well as high transportation costs, but other factors likely hinder efficient market integration. Small-scale farmers often lack accurate or sufficient information about prices in other geographical areas, or any guarantee that they will be able to sell their goods elsewhere. Yet, research suggests that better information alone is not enough to persuade farmers to move their food surpluses to areas where there are deficits.2 Addressing the imbalance in food supply, and simultaneously increasing farmer income, may require a multi-pronged approach that tackles intermediation, information, and contracting barriers at once.

Context of the Evaluation:

A large portion of people in Uganda face food insecurity, though rates vary regionally. According to a 2013 report, almost half of Ugandans are food energy deficient.3 Over a third have low dietary diversity, but that number reaches 55 percent in the western region—a region also burdened with the highest rates of childhood stunting.     

AgriNet, Ltd. the main project implementer, is the largest private-sector market brokerage firm in Uganda. AgriNet signs contracts with major buyers and then organizes supply from farmers. The company also has a “trader alerts” system, which feeds basic market information to farmers to help them bulk and sell at higher prices than are available on spot markets.

Details of the Intervention:

Researchers will carry out a randomized evaluation in 230 markets in 110 sub-counties in northeast, western, and central Uganda. The aim is to evaluate the impact of AgriNet’s mobile technology-enhanced trader alerts system on farmers and intermediaries’ profits, intermediaries’ method of connecting with farmers, additional market linkages, and price dispersion. Three institutions—AgriNet, Kudu, and IPA—will collaborate to implement and evaluate the program. 

The study team will randomly assign half of the sub-counties to the treatment group and half to the comparison group. In each of the 130 markets in the treatment group, AgriNet will recruit, train, and certify four commission agents.These agents, recruited from a pool of local traders, will actively link farmers to large buyers and operate the enhanced trader alerts system. The amount of grain farmers have for sale will be uploaded onto the trader alert platform and broadcasted to potential buyers and vice versa. Kudu, the mobile application integrated in the trader alerts, will serve to electronically bulk the grain, allowing buyers to view what is available for purchase at the village-level. In addition, traders will send information on local market prices to Kudu via SMS. Kudu will post this information daily, enabling farmers to sell when prices are most favorable and to negotiate for the prevailing market price. 

In the 55 sub-counties that serve as a comparison group, AgriNet will not execute any activities for the duration of the study.

To evaluate the impact of the project, IPA will conduct three types of surveys—an initial survey of farmer households, a survey of traders, and a market price survey—in both treatment and comparison markets. The trader survey will track the revenue, income, volumes, crops, and locations of trading for five buyers in each studied market as well as for commission agents in the study.  The agricultural household survey will be administered to 11 households in each catchment area that are active in agricultural markets (i.e. not subsistence farmers) around study markets, for a total of 3,000 households.

In addition, the market price survey will measure the impact of the project on price dispersion. For each market, IPA will recruit two traders, who are aware of market prices, train them to use the SMS survey system, and pay them (with mobile phone credit) to answer a detailed market survey every two weeks.

Results and Policy Lessons:

Results forthcoming.


[1] Feed the Future, East Africa Regional Profile.

[2]Fafchamps, Marcel, and Bart Minten. "Impact of SMS-based agricultural information on Indian farmers." The World Bank Economic Review 26, no. 3 (2012): 383-414.

[3] World Food Program; Uganda Bureau of Statistics (UBOS). “Comprehensive Food Insecurity and Vulnerability Analysis, Uganda,” April 2013.

Starting a Lifetime of Saving: Teaching the Practice of Saving to Ugandan Youth

Improving financial literacy and access to bank accounts may help youth save, allowing them to meet current financial needs and invest in their futures. In Uganda, researchers evaluated whether offering financial education or group savings accounts to church-based youth groups increased savings. They found that total savings and income increased among youth offered financial education, group savings accounts, or both education and group accounts.

Policy Issue:

Promoting financial literacy and providing access to bank accounts have become popular approaches to help the poor save. Increased savings may help individuals meet day-to-day financial demands and invest in their futures. Furthermore, increasing the savings rate in the general population may help promote large-scale changes in a country’s economy by allowing increased investment in productive resources. In order to maximize the benefits of increased savings at both the individual and country level, it may be most effective to encourage youth to save. Young people may be more likely to adopt new habits, and they have many working years ahead of them. A growing body of literature investigates whether either financial education or bank access affect savings behavior. 

Context of the Evaluation:

Uganda has a very young population: in 2006, 52 percent of the country’s population was under 15 years old and 29 percent of the country’s adult population was between 15 and 34.1 In addition, Uganda has extremely low savings rates, even relative to its neighbors. Between 2001 and 2003, the average savings rate among Ugandan households was 5.2 percent, compared with an average rate of 12.7 percent in neighboring Kenya.2

Researchers partnered with the Foundation for International Community Assistance (FINCA) and the Church of Uganda in this evaluation. FINCA, whose mission is to provide financial services to the world’s lowest-income entrepreneurs, has worked in Uganda since 1992. The Church of Uganda is an Anglican church, representing the second largest religious group in the country. As of the 2002 census, 36 percent of the population considered themselves affiliated with the church. The Church maintains a large network of youth fellowship groups, based at village churches around the country. The youth groups participating in this study had an average of 40 members. The average age was 24.5 and 40 percent of members were female.

Details of the Intervention:

Researchers evaluated whether offering financial education or group savings accounts to Ugandan youth groups increased savings. The study involved 240 Church of Uganda youth groups, which were randomly assigned to receive financial education, a group savings account, both financial education and a savings account, or neither intervention. There were 60 youth groups in each arm of the study.

The curriculum for the financial education intervention was designed in partnership with Straight Talk Foundation and Freedom from Hunger. The ten-session, fifteen-hour curriculum taught concepts and skills for improving savings behavior, including role-playing the differences between saving and borrowing to achieve a goal, how to keep a budget, and strategies for successfully discussing sensitive topics around money.

Researchers partnered with FINCA to design a group savings account without fees and with simple account-opening procedures, which minimized common barriers to opening accounts. Each club had only one account and was responsible for maintaining a ledger with individual members’ savings. Clubs were also required to make a deposit within thirty days of opening the account and to maintain a minimum balance of 50,000 UGX (US$20).

Results and Policy Lessons:

Financial literacy: Members of youth groups receiving financial education had higher levels of financial knowledge, awareness, and numeracy. Youth in groups receiving financial education only scored 0.04 standard deviations higher than the comparison group on an index combining questions relating to financial literacy. Youth in groups receiving both financial education and group accounts scored 0.06 standard deviations higher than the comparison group. Youth in groups receiving account access only did not score any better than the comparison group.

Bank savings: Using administrative bank data on the group accounts offered in the intervention, researchers found that offering financial education in addition to account access increased savings more than offering the account alone. Averaging across groups receiving account access only and groups receiving account access plus financial education, only 14 percent of members used the account. However, those who did use the accounts saved non-trivial amounts: an average of 15,000 UGX  (US$6) in the account-only group and an additional 4,000-7,000 UGX (US$1.60-2.80) among those who also received financial education.

Total savings: All three interventions designed to promote savings increased participants’ total savings. This measure included saving by storing at home, by having another person hold the money, or by buying durable goods that could later be sold, in addition to savings held at a formal bank. In contrast to the administrative bank data, these results did not show that financial education and account access work together to promote savings, but rather that each approach can encourage increased savings on its own.

Income: Individuals in all three treatment groups reported earning 10-15 percent more income than individuals in the comparison group. However, researchers were unable to determine whether this effect resulted from individuals working more in order to increase their savings or from individuals using savings to make investments that generated income.

Are financial education and formal savings accounts complements or substitutes in the medium to long-term? Do the impacts on behavior and income persist over time? What are the mechanisms underlying the increase in earned income? To answer these questions, a follow-up of this evaluation three years after the commencement of the intervention is currently being conducted by IPA in Uganda, under the Financial Capability Research Fund. Results forthcoming.


[1]Uganda Bureau of Statistics (UBOS) and Macro International Inc. 2007. Uganda Demographic and Health Survey 2006. Calverton, Maryland, USA: UBOS and Macro International Inc. Page 11.

[2] Bank of Uganda research department, Sept. 14, 2005.  Found in “Savings Habits, Needs and Priorities in Rural Uganda.” Prepared by Richard Pelrine, Olive Kabatalya. Rural SPEED and Chemonics International.  Produced by USAID, September, 2005. 

Unconditional Cash Grants for People with HIV/AIDS in Uganda

Research has shown that HIV/AIDS impacts not only the health of infected individuals, but also their financial security, and the financial security of their households, often aggravating existing poverty. Researchers will introduce unconditional cash grants, coupled with financial planning sessions, to people living with HIV/AIDS to evaluate the impact on the health and financial security outcomes of participants.

Policy Issue:

Evidence indicates that HIV/AIDS affects not only infected individuals, but also the health and wealth of their households. When a household member is affected by HIV/AIDS, it can exacerbate existing poverty by hindering productivity and imposing additional costs on households, such as health care and funeral costs. The link between HIV/AIDS and poverty has caused some researchers and policymakers in recent years to examine financial assistance as a potential tool in the fight against AIDS.1 This study sheds light on this relationship by evaluating the impact of providing unconditional cash grants, coupled with financial planning sessions, to people living with HIV/AIDS.

Context of the Evaluation:

In Uganda, approximately 1.5 million people, or 7.2 percent of the population, are living with HIV.2 The high infection rate is coupled with high rates of poverty, especially in rural areas. In 2012, Uganda ranked 161st among 187 countries on the United Nations Development Program’s Human Development Index.

The AIDS Support Organization(TASO), the implementing partner in this study, is a Ugandan NGO founded in 1987. TASO has provided HIV/AIDS services to over 200,000 individuals since its inception, and now has eleven service centers spread across Uganda.TASO is looking for new evidence-based ways of supporting their clients, and is prepared to expand microfinance and grant opportunities across Uganda if there is compelling evidence that these programs improve patients’ lives.

Details of the Intervention:

To evaluate the impact of unconditional cash grants on the health and financial security outcomes of people living with HIV/AIDS, researchers will carry out a randomized evaluation of a cash grant program, jointly designed by researchers and TASO, and administered by TASO. The unconditional cash grant program will provide cash transfers of 350,000 Ugandan shillings (approximately US$138), with no strings attached, to HIV/AIDS positive TASO clients.

Approximately 2,200 HIV/AIDS positive TASO clients, ages 18-60 will be randomly divided into one of four groups: i) a treatment group that will receive cash transfers with no accompanying instructions on how the money should be spent, ii) a treatment group that will receive cash transfers plus financial counseling, iii) a treatment group that will be told they will receive cash transfer after one year, and iv) a comparison group that will not receive any intervention. The third treatment group will enable researchers to see how participants’ financial status and planning changes, or if it changes at all, when they know they will receive money in one year.

The quarter of clients that receive both cash grants and financial counseling will meet with a financial counselor twice at a TASO center, with six days between the meetings, and then will receive the grant at the end of the second one-hour meeting. At the meetings, the counselors will help clients think through and plan for the grant. Discussions will focus on topics such as setting realistic expectations, prioritizing expenses, handling family members’ expectations of the grant, and resisting temptations. Furthermore, the counselors will go into detail about income generating activities, loans and/or saving, depending on the client’s particular interests.

Results and Policy Lessons:

Results forthcoming.


[1] Sengupta, Rajdeep, and Craig P. Aubuchon. "The microfinance revolution: An overview." Federal Reserve Bank of St. Louis Review 90, no. January/February 2008 (2008).

[2] UNAIDS. Country Report Uganda. 2012. Available at:

Contractual Partnerships for Bean Growers in Central Uganda

Small-scale farming accounts for over 90 percent of agricultural output in Sub-Saharan Africa, and agricultural productivity on these farms is low, on average.  Contractually linking farmers to buyers may improve farmer profits and stimulate economic growth, but more evidence is needed on how these agreements impact farmers’ livelihoods and the crops they grow. This pilot evaluation with bean farmers in Uganda measures the impact of contracts between farmers and buyers on income, beans sold, inputs used, and a variety of other outcomes.

Note: This is a pilot study.

Policy Issue:

Small-scale farming characterizes agriculture in much of Sub-Saharan Africa. More than two-thirds of holdings are less than one hectare on average and these small plots produce over 90 percent of agricultural output.1 Agricultural productivity in Africa is, on average, low.2 Transitioning from low productivity, semi-subsistence agriculture to high productivity, commercialized agriculture has been a core theme of development. Since poverty is concentrated in rural areas among small-scale farmers, reducing overall poverty is thought to start with these farmers. Beyond increasing farm incomes, growth in agricultural productivity may also stimulate linkages to the rural economy outside the agricultural sector, causing further economic growth.3

Programs that contractually link farmers to buyers have become popular in the development sector, as such programs may reduce intermediaries and increase farmers’ profits. However, more evidence is needed regarding the impact of these contracts on farming practices and farmers’ livelihoods.

Context of the Evaluation:

In Uganda, agriculture employs 70 percent of the labor force and accounts for 20 percent of GDP, making it the backbone of the economy.4 Ninety two percent of the poor live in the countryside, and 89 percent of the population is classified as rural.5  In 2010, Uganda was ranked second in production of beans after Tanzania in the East Africa.

Myanzi Area Cooperative Enterprises, a partner in this evaluation, is a Uganda-based agricultural cooperative that works to create market linkages for rural producers, gather and disseminate market information, bulk agricultural products, and promote technology use to increase production, among other objectives.

Details of the Intervention:

This pilot study aims to determine how access to improved markets, by contractually linking bean farmers to bulk buyers, impacts farming practices. Data collection for the study will be accomplished through household surveys carried out before contracting and after the harvest.

The study includes 500 bean farmers in the Central Region of Uganda randomly assigned to a treatment group or control group. The treatment households will receive a visit from project staff encouraging them to sign up for the contract that links farmers to the bulk buyer.

If a large enough proportion of the households in the encouraged or treated group sign up for beans contract, the analysis will proceed by comparing income, beans sold, inputs used, and a variety of other outcomes, on the group that signs up for the contracts relative to the one that is not offered the contracts. Differences in outcomes across groups constitute unbiased estimates of the effect of the intervention on outcomes at “complying” households, i.e., households that were motivated to apply for the program by the encouragement.

Results and Policy Lessons:

Results forthcoming.

[1] International Food Policy Research Institute. “Ending Hunger in Africa: Prospects for theSmall Farmer.” p. 2

[2] International Center for Trade and Sustainable Development. “Raising agricultural productivity in Africa: The energy challenge.” May 1, 2008.

[3] Haggblade, Steven, Peter Hazell, and James Brown. "Farm-nonfarm linkages in rural Sub-Saharan Africa." World Development 17, no. 8 (1989): 1173-1201.

[4]Feed the Future. Uganda, country profile.

Muthoni Ngatia

Smoothing the Cost of Education: Primary School Saving in Uganda

Even when there are no official school fees, the financial burden of purchasing uniforms, books, and other school supplies prevents low-income students from remaining in school. In Uganda, researchers tested whether a school-based savings program improved academic performance and reduced dropout rates by enabling students and their families to save for school-related expenses. A version of the program that labeled savings for educational purposes, rather than fully committing money to educational expenses, increased the amount students saved, expenditures on educational supplies, and test scores.
Policy Issue:
Although many countries in Sub-Saharan Africa have close to universal primary school enrollment, many students drop out before completing primary school or fail to continue to secondary school. While children drop out for a number of reasons, financial concerns are often an important factor. Even when governments eliminate school fees, there are still many costs associated with attending school. Providing basic school supplies such as uniforms, pens, pencils, and workbooks is often a significant challenge for low-income families. Furthermore, these families may lack access to formal savings services, making it difficult to set aside money for education. Even when families do have some savings, there is no guarantee they will use the money for educational expenditures. This evaluation assesses the impact of a school-based savings program that aims to encourage students and their parents to save for educational expenses.
Context of the Evaluation:
Uganda’s primary school enrollment rates have greatly increased since the government began providing free universal primary education. Retaining pupils, however, is more difficult and as few as 32 percent of children entering primary school complete all seven grades. While the government covers the cost of teachers and schools, many Ugandan primary schools require uniforms, and families are responsible for providing school supplies such as stationary and workbooks. The financial strain of buying these supplies is often too high for the family to sustain, and is cited as a major reason for children dropping out of school.
Description of the Intervention:
Researchers partnered with the Private Education Development Network (PEDN) and FINCA Uganda to implement and test the “Super Savers” program in public primary schools. Children in grades five through seven, the final three years of primary school, were given the opportunity to deposit money into lockboxes on a daily or weekly basis. The money was deposited into the school’s bank account at the end of each trimester. The bank accounts did not earn interest. At the beginning of the next trimester, bank representatives returned to the school to disburse the funds. On the day the funds were paid out, PEDN organized a small market at each school where students could purchase school supplies or school services such as practice exams or tutoring sessions.
Schools were randomly assigned to have students’ savings returned in one of two ways:
  • Voucher payout: students received their savings in the form of a voucher that could only be used to buy supplies or school services at the market set up at the school. This created a binding commitment to spend savings on educational expenditures.
  • Cash payout: students received their savings in cash, which meant they could spend the funds either at the market set up at the school or however else they chose. 
Students were notified of the kind of payout they would receive at the beginning of the program. There were 39 schools in each group, and an additional 58 schools served as a comparison group  received no savings account.
Half of the schools in each payout group were also randomly assigned to receive parent outreach, in which workers from PEDN hosted a workshop for sixth- and seventh-grade parents to describe the various ways they could support their children’s education and to promote the savings program as a tool to help families finance school expenditures.
Results and Policy Lessons:
Researchers found that students deposited significantly more when their savings were returned in cash, rather than vouchers. On average, students in schools that received cash payouts deposited between 2,200 and 2,340 Ugandan shillings, while the average student who received voucher payouts deposited between 1,120 and 1,180 shillings.
The purpose of the voucher payouts was to commit students to spend their savings on educational expenses. Cash payouts, on the other hand, imposed no restrictions on the use of savings, but did provide a weak commitment to spend savings on educational expenses by basing the savings program in schools and timing payouts to correspond with markets for school supplies. This weaker commitment may have appealed to students who value flexibility on how to spend their savings, while the voucher treatment’s stronger commitment may have discouraged them from saving.
When combined with parent outreach, students who received cash payouts were significantly more likely to have a complete set of school supplies. They also had test scores that were 0.11 standard deviations higher than the comparison group. There were no significant positive effects on school supplies or test scores among students who received cash payouts without parent outreach or among students who received vouchers, with or without parent outreach. These results suggest that combining cash payouts from savings accounts with parental outreach can lead households to spend savings on education and improve student learning.

Strengthening Local Political Accountability in Uganda

In Uganda, district governments are responsible for providing vital public services such as healthcare and education, but measures of government accountability are relatively weak, leading to under provision and low quality of services. Researchers are evaluating the impact of two systems designed to improve local government accountability – a text-messaging system for opening a direct channel of communication between citizens and district councilors, and a system for scoring elected district councilors – on their effort in improving the government’s provision of public services.

Policy Issue:

Government institutions are widely understood to be more effective purveyors of public services when they are accountable to citizens. Voters in many electoral democracies in low-income countries have limited information about their representatives’ political decisions on a national level.[1] One potential solution to this problem is a strategy of decentralization, wherein decisions are increasingly made by local councils.[2] However, there is limited accountability for local councils as well as national governments.[3] Policymakers are interested in strategies for improving accountability on a local level.  Recent research suggests that providing citizens with information about elected officials’ performance, and harnessing mobile technology to strengthen the links between office holders and their constituents, may be potential mechanisms for improving accountability and awareness of political issues.[4] While there is some evidence about the effectiveness of these approaches at the national level, little is known about them at the local level.[5]  This study aims to address this evidence gap.

Context of the Evaluation:

Uganda has decentralized its government by implementing a system of local councils. Even with this system of government, there are few ways of ensuring government accountability to constituents. In practice, citizens’ engagement with local government officials is low. Village-level meetings rarely occur, few attend budget meetings, and the language and style of meetings effectively exclude many voters.[6]  As a result, many attempts to improve public services take place outside the existing government institutions. However, local government institutions largely control the allocation of resources and the standards for the provision of public services like healthcare and education, so outside interventions are greatly limited in their ability to have a large-scale impact on public services.

Uganda-based Advocates Coalition for Development and Environment (ACODE) has been operating two programs that explicitly aim to strengthen accountability and improve public services. One program uses text messages to open a new channel of direct communication between local government councilors and citizens, which allows citizens to report public services they find inadequate. The other program, the Local Government Councilor Scorecard Initiative, disseminates information about councilors’ performance, specifically with the goal of improving the delivery of public services. Scores seek to measure councilors’ performance in four key areas: monitoring public services, interaction with lower local governments, execution of legislative duties and contact with their electorate.

Details of the Intervention:

Researchers are carrying out a randomized evaluation to test whether local councilors improve their performance when citizens receive, and can share, information about their councilors’ performance. The study includes approximately 8,000 citizens in 20 districts, and some 400 local government councilors. Researchers are evaluating ACODE’s different programs and also comparing different levels of information sharing and citizen involvement.

Within the districts, 208 sub-counties are selected and randomly assigned to one of four treatment groups, containing 52 sub-counties each. The sub-counties receive one of the following:

(1.) “Scorecard dissemination” of councilor performance information: In these sub-counties, ACODE holds twice-yearly community meetings where they provide information to citizens on how their councilors rank in performance in comparison with other councilors, with councilors’ scores marked on a card. The scorecard is also provided to the councilors themselves. Citizens also receive updates on their mobile phones and through radio ads on their councilors’ performance.

(2.)  SMS program: In these sub-counties ACODE holds community meetings to inform citizens and service providers of the new text-messaging service. Participants in these countiescan send text messages to their councilor reporting deficiencies in service provision. Throughout the year, ACODE sends reminders to citizens who had participated in the community meetings in which the SMS program has been introduced.

(3.) Both the scorecard dissemination and the SMS program: Sub-counties randomly assigned to this treatment group receive both programs described above.

(4.) Comparison groupThese sub counties received neither of the two programs. However, it should be noted that ACODE does provide councilors in these counties with their scores in twice-yearly district level meetings.

Researchers will measure the relationships between public services and local councilors, and the level of councilors’ engagement in working with district technocrats to lobby for better services in their constituencies. Researchers will also use random audits of schools and clinics in each sub-county in the study area to estimate whether greater effort by treatment councilors translates to better services at the unit (school/clinic) level.

Results and Policy Lessons:

Results forthcoming.

[1] Pande, Rohini. "Can informed voters enforce better governance? Experiments in low-income democracies." Annu. Rev. Econ. 3, no. 1 (2011): 215-237.

[2] Pande, 2011.

[3] International Development Department, School of Public Policy, University of Birmingham. “Local Government Decision-Making: Citizen Participation and Local Government Accountability.” IDD Research News, May 2002: 1-3.

[4] Humphreys, Macartan, and Jeremy Weinstein. "Policing Politicians: Citizen Empowerment and Political Accountability in Uganda Preliminary Analysis." Columbia and Stanford Universities (2012).

[5] Humphreys and Weinstein, 2012.

[6] Devas, Nick, and Ursula Grant. "Local government decision‐making—citizen participation and local accountability: Some evidence from Kenya and Uganda." Public Administration and development 23, no. 4 (2003): 307-316.

Demand for Rainwater Harvesting Devices in Uganda

Accessing safe drinking water is a major challenge in many developing countries. In order to improve access to safe drinking water, Relief International (RI) has developed a rainwater storage device (RSD), which consists of a rubber bag approximately 1.5m across and 1.5m tall when full. Researchers are evaluating this new technology in Kamwenge district in Uganda. 

Policy Issue: 

In many developing countries, poor access to safe drinking is an acute problem, with both health and social repercussions. Lack of safe water for drinking, bathing, and other household tasks is the primary cause of diarrheal diseases, which account for 15 percent of deaths among children under five years of age.[1] Poor access to water also entails large time costs associated with gathering water. In some parts of Africa, women spend up to eight hours per day collecting water. New technologies, such as rainwater storage devices, could improve access to safe drinking water and decrease the time needed for water collection. However, such new technologies are only useful to the extent that they are affordable and acceptable to the intended beneficiaries. Before any large investments are made in the development and distribution of a technology, it is necessary to determine the potential size of the market, the most effective marketing strategies to promote adoption, and the potential impacts it could have on the lives of the poor.

Context of the Evaluation: 

In order to improve access to safe drinking water, Relief International (RI) has developed a rainwater storage device (RSD), which consists of a rubber bag approximately 1.5m across and 1.5m tall when full. The bag is held up by a simple earthen foundation and is fed by a series of gutters. It can hold up to 1000 liters of water, which is estimated to meet the basic needs of a family of five for ten days. 

Researchers are evaluating this new technology in Kamwenge district in Uganda. Residents of Kamwenge are particularly likely to benefit from a rainwater storage device, as the district receives substantial rainfall during the two rainy seasons – the first and smaller of the two lasts from the end of February to the end of April, while the second and longer season lasts from mid-September to the beginning of December. 

Details of the Intervention: 

This study will assess the demand for rainwater storage devices and determine potential marketing strategies. Specifically, researchers will randomly vary the incentives and marketing conditions associated with the sale of rainwater storage devices to different households. Researchers will experimentally vary the price for the device by offering discount vouchers to random subsets of households.

Researchers will also randomly apply two different marketing schemes across villages. In the first scheme, a product ambassador will be chosen from each village and given training and materials to promote the device within the village. In the second marketing scheme, the first household within each village that purchases the device at full price will receive free installation. Both marketing schemes are intended to increase locally available information about the device and promote take-up by others in the village. 

The intervention will be implemented in two distinct waves spread 6 months apart, in order to study the importance of information transmission in generating demand for the new technology. For instance, it may be the case that second-wave households would have had some indirect experience with the new technology through their friends who adopted in the first wave, affecting their likelihood of adoption. The two-wave strategy also creates the opportunity to examine whether the overall level of demand changes once society becomes more familiar with the product and its price is anchored. 

A follow-up survey will measure women’s participation in the workforce, child school attendance, and changes in household economic activity among adopters and non-adopters.

Results and Policy Lessons

Results forthcoming.

1. World Health Organization (WHO). World Health Statistics 2011.

Mushfiq Mobarak

Returns to Consulting for Women Entrepreneurs

This study of the impact of entrepreneurship training and mentoring in Uganda evaluates a program which aims to help women entrepreneurs develop the skills they need to run thriving businesses. In addition to testing the overall impact of the program on participating entrepreneurs and the businesses with whom they compete or collaborate, the study will demonstrate the relative cost-effectiveness of intensive, personalized training versus a less intensive, standardized approach. The program will be advertised to female business owners in urban Central Uganda. As the training is expected to be oversubscribed, entrepreneurs who meet basic eligibility criteria will be randomly assigned to receive high-intensity personalized training, low-intensity standardized training, or no training (the comparison group). The randomized design allows systematic differences in outcomes to be attributed to differences between the treatment and control groups, and thus allow researchers to learn more about the impact of business skills training on profits, business size, and other outcomes for female entrepreneurs.

For additional information on current SME Initiative projects, click here.

Policy Issue:

Small and medium enterprises (SMEs) are often viewed as potential engines for innovation, employment, and social mobility, and promoted as vehicles for economic growth.  In many developing countries, SMEs make up a particularly large part of the economy, yet data suggest that very few grow into larger businesses. If SMEs have such growth potential, what prevents them from expanding?

Human capital constraints may be key, especially if having adequate managerial skills in place is a prerequisite for accessing other resources, such as financial services. Many “business development services” and “entrepreneurship training” programs target SMEs in developing countries, but there is almost no systematic evidence on the effectiveness of such programs.  This project evaluates a training and mentoring program in Uganda aimed at helping female entrepreneurs develop the skills they need to run thriving businesses. The objective of the evaluation is to measure the impact of an increase in “managerial human capital” on business outcomes for entrepreneurs who receive training, as well as the spillover impact of such an intervention on competing and collaborating businesses. It also compares the relative cost-effectiveness of skill transfer through a more personalized, time- and resource-intensive training approach, versus a standardized, less intensive one.

Context of the Intervention:

TechnoServe, an international non-profit business development organization, implements a business training program called Women Mean Business (WMB) in four cities in Central Uganda—Kampala, Entebbe, Jinja and Mukono.   Since 2008, almost 600 women have received business skills training through the WMB program.  A market survey of SMEs in these four cities, conducted by IPA, revealed that approximately 54% of all businesses interviewed were owned or managed by women.  However, owners of small businesses – and especially female entrepreneurs – may lack management skills and information about how to access financial services and other resources, limiting their ability to improve and grow their businesses.  For example, although women own nearly 40% of businesses with registered premises, they obtain only 9% of all credit disbursed.[1]The WMB program aims to provide female entrepreneurs with tools and training to better manage and grow their businesses. 

Details of the Intervention:

Eligible entrepreneurs will be randomly assigned to one of three groups: In Depth training, Light Touch training, or a comparison group.  Program activities for both tracks will take place over the course of a year, and will be implemented by TechnoServe staff or outside consultants and mentors trained and supervised by TechnoServe.

In the first year of the program, Light Touch track participants attend classroom training sessions on topics such as financial management, sales/marketing, customer relations and human resource management.  Each topic will be covered in a two-day training session, with one session each month.  Participants will also be placed in sector working groups (e.g. manufacturing, retail, services), which will meet for additional, targeted training lessons and field activities.  In the second year of the program, refresher training sessions will be held to provide more clarity on the topics and address any specific issues faced by the participating businesses.  Finally, Light Touch participants will receive individual visits from a TechnoServe counselor to discuss any business-specific challenges they face.

Women in the In Depth track will receive all of the services offered to the Light Touch group, and in addition, will be matched with student coaches selected from local business schools.  These coaches will work with the women for eight weeks in the first year of the program to develop a five year business plan.  In the second year, the women will be matched one-on-one with mentors, who they will work with over three months to implement the business plan and adopt the lessons from the various training activities. 

Before the start of the WMB program, a baseline survey will gather information on each business's operations, products and sales, employment, and finances, as well as background information on the owner/manager.  Eight to twelve rolling follow-ups surveys will be conducted over the course of two years to gather data on business performance during and after the one-year WMB training program.  A final endline survey will be conducted two years after the baseline survey and one year after the WMB program ends. 

Results and Policy Lessons:

Results forthcoming.

[1] Ellis, Amanda, Claire Manuel, and C. Mark Blackden, “ Gender and Economic Growth in Uganda: Unleashing the Power of Women,” Directions in Development 2006. 

Improving Loan Repayment through Positive Incentives in Uganda

Policy Issue: 

Financial markets in developing countries can be hampered by a lack of basic financial infrastructure such as functioning credit bureaus, uniform disclosure rules or the ability to use collateral. These limitations can substantially increase the cost of lending for many banks since there is much less information about the overall applicant pool and enforcement of loans is more difficult. The lack of functioning financial systems can impede any enforcement or screening mechanism that operates through negative incentives, if borrowers who have defaulted on one bank can easily access other lenders. To ensure timely repayment, banks therefore have to rely on more innovative positive incentive schemes.

Context of the Evaluation: 

Uganda Microfinance Limited (UML) is a microfinance institution, which primarily lends to small businesses through its 27 branches located across Uganda. In 2008, UML (now called Equity Uganda) had over 25,000 borrowers, a loan portfolio of US$24 million, and a default rate of 4 percent. Although all UML borrowers must have some form of collateral to cover at least 80 percent of the principal loan amount, it is very hard to actually seize the assets if a customer defaults. As Uganda did not have a credit bureau at the time of the study, UML did not have the ability to incentivize timely repayment based on the threat of affecting a borrower’s credit history.

Details of the Intervention: 

In collaboration with UML, researchers evaluated the effectiveness of three positive incentive schemes designed to help to reduce late loan payments among small business owners.

In 2008, all UML customers who had been approved for a business loan were randomly assigned to one of the three treatment groups or a comparison group. In the first treatment - “Cash Back” - which provided incentives for on-time repayment, borrowers received a cash back payment equivalent to a 25 percent reduction of the interest rate if they made all their monthly payments on time. However, fast-growing firms with significant investment opportunities might be willing to forgo the cash back payment if the returns from investing are higher than the benefit of paying on time. In attempt to isolate the incentive effect for such fast growing firms, the second treatment – “Future Interest Rate Reduction” - gave customers a 25 percent reduction in the interest rate of their next loan, if current loan payments were all made in time. In the third treatment – “SMS Reminders” - borrowers received SMS reminders every month three days before the payments are due.

If small businesses strategically delay repayment since they know that lenders have only limited enforcement mechanisms, then the provision of incentives for on-time payments should increase repayment by reducing the benefits of this behavior, while sending SMS reminders should not have any impact. In contrast, if late payments were predominantly a function of the inability of small business to manage their finances, steeper incentives would not help, since payment failures are simply a function of their inability to manage the finances of the business. SMS reminders, on the other hand, might help prevent firms missing payment due to oversight.

Monthly loan repayment information was collected from the bank between March 2008 and June 2009. This data was complemented by personal and business characteristics obtained from the loan application and loan appraisal forms.

Results and Policy Lessons: 

Impact on Loan Repayment: The three treatments had similar effects on borrower repayment behavior. Borrowers in the “Cash Back” incentive group were 8.6 percent more likely to make all payments on time than the control group. The offer of a “Future Interest Rate Reduction” increased the probability of paying on time by 7.3 percent, relative to the control group. Perhaps most interestingly, borrowers in the “SMS Reminder” group, which was almost costless for the bank to implement, were 9 percent more likely to pay every installment on time.

Heterogeneous Treatment Effects: The effect of the treatments varied significantly across different subgroups of borrowers. The impact of “Cash Back” incentives were stronger for customers with smaller loans and less banking experience, the “Future Interest Rate Reduction” seemed to be most effective for customers with larger loans, while the “SMS Reminders” were particularly effective for younger customers.

Evidence supports the hypothesis that small businesses in developing countries pay late not because of strategic reasons but because they suffer from a lack of financial management, which affects their ability to make payments on time. This has broader implications for the design of credit products. The repayment behavior of a borrower may be partly driven by simple product details, such as the ease with which the borrower can pay the loan. Thus, loan programs that facilitate easy repayment or frequent reminders may improve loan repayment behavior and reduce the cost of lending.

Evaluating Village Savings and Loan Associations in Uganda

Microfinance institutions have increased access to financial services over the last few decades, but provision in rural areas remains a major challenge. Traditional community methods of saving, such as ROSCAs can provide an opportunity to save, but do not allow savers to earn interest on their deposits as a formal account would, or provide a means for borrowing. Savings Groups attempt to address these shortcomings by forming groups of people who can pool their savings in order to have a source of lending funds.

Policy Issue:

Although during the last decades microfinance institutions have provided millions of people access to financial services, provision of access in rural areas remains a major challenge. It is costly for microfinance organizations to reach the rural poor, and as a consequence the great majority of them lack any access to formal financial services.  Traditional community methods of saving, such as the rotating savings and credit associations called ROSCAs, can provide an opportunity to save, but they do not allow savers to earn interest on their deposits as a formal account would.  In addition, ROSCAs do not provide a means for borrowing at will because though each member makes a regular deposit to the common fund, only one lottery-selected member is able to keep the proceeds from each meeting.

Village Savings and Loan Associations (VSLAs) attempt to overcome the difficulties of offering credit to the rural poor by building on a ROSCA model to create groups of people who can pool their savings in order to have a source of lending funds.  Members make savings contributions to the pool, and can also borrow from it.  As a self-sustainable and self-replicating mechanism, VSLAs have the potential to bring access to more remote areas, but the impact of these groups on access to credit, savings and assets, income, food security, consumption education, and empowerment is not yet known. Moreover, it is not known whether VSLAs will be dominated by wealthier community members, simply shifting the ways in which people borrow rather than providing financial access to new populations.

Context of the Evaluation:

The Village Savings and Loans program in this study is implemented in rural communities across seven districts in Eastern, Western, and South-Western Uganda.  Community members are predominantly engaged in farming or animal breeding depending on the region. With little access to formal financial institutions, these small farmers do not have the opportunity to invest in agricultural inputs like fertilizer that could increase their income.

Description of the Intervention:

Three hundred ninety-two villages were selected to participate in this study and randomly assigned to a treatment or comparison group. Half of the villages in the treatment group were introduced to the VSLA model by community-based trainers who received an orientation by CARE and its local implementing partners. 

Community-based trainers present the model to villagers at public meetings. Those interested in participating are invited to form groups averaging about twenty and receive training.  These groups, comprised mostly of women, meet on a regular basis, as decided by members, to make savings contributions to a common pool.  At each meeting, members can request a loan from the group to be repaid with interest. This lending feature makes the VSLA a type of Accumulating Savings and Credit Association (ASCA) providing a group-based source of both credit and savings accumulation. CARE’s VSLA model also introduces an emergency fund, allowing members to borrow money for urgent expenses without having to sell productive assets or cut essential expenses such as meals.

This study will assess the impact of VSLA trainings and group membership on access to credit, savings and assets, income, food security, consumption education, and empowerment.

Results and Policy Lessons:

Results forthcoming.  

We are also working with CARE to evaluate their VSLA programs in Ghana and Malawi.

Using Messaging and Package Design to Increase Treatment Compliance with Antimalarial Medication

The development of parasite resistance to Chloroquine was a major factor in the resurgence of malaria in Africa over the past two decades. Successive generations of antimalarials have become more expensive to produce and less able to withstand parasite resistance. Artemisinin Combination Therapies (ACTs) are currently the only remaining effective antimalarial and preserving the efficacy of these drugs is essential to controlling malaria mortality and morbidity. A major driver of parasite resistance is non-compliance with treatment (“non-adherence”). Pilot evidence from Uganda generated for this project suggests that only 55% of people purchasing ACTs over-the-counter complete the full treatment course. This is a distressingly low level of treatment compliance.

This study explores methods to improve treatment compliance through improved packaging and targeted messaging on over-the-counter ACTs. We explore both the content of messaging and the design and quality of the packaging, including pictorial instructions for illiterate consumers. We also test whether a confirmed diagnosis for malaria increases the rate at which people finish their medicine. This study will make recommendations to pharmaceutical manufacturers and African governments on cost-effective ways to increase compliance. 

Jessica Cohen, Gunther Fink

Feasibility and Impact of Malaria Diagnostics in Ugandan Drug Shops

Malaria is one of the most common causes of illness in Sub-Saharan Africa. The standard first response to a suspected malaria episode is to purchase over-the-counter medication from a local pharmacy, bypassing the formal health care system altogether. Evidence is emerging that a large share of illnesses for which antimalarial medication is taken are not in fact malaria, but are rather bacterial or viral infections. A high rate of inappropriate treatment is problematic because it delays proper diagnosis and treatment for the true cause of illness, wastes precious resources (such as antimalarial subsidies) and possibly accelerates antimalarial drug resistance.

This study explores a method to increase access to affordable malaria diagnostics through retail sector drug shops. We investigate supplier incentives to sell and customer incentives to purchase rapid diagnostic tests (RDTs) for malaria in drug shops in Eastern Uganda. We sell heavily subsidized RDTs to drug shops and allow them to set the price, while simultaneously experimenting with methods to increase customer demand through behavior change communication messaging and social learning. The study also experimentally varies training modules for drug shop owners, in some cases emphasizing their role as primary health care providers in remote communities with poor access to the formal public health system. Finally, we exploit Uganda’s underlying variation in malaria endemicity to explore how financial incentives to sell RDTs are influenced by expected malaria positivity in an effort to understand the circumstances in which RDT subsidies can be most cost-effective.

Jessica Cohen, Gunther Fink
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