Context:

Peru is a developing country rife with healthcare challenges. According to the World Health Organization, children have a 25% chance of dying before reaching the age of 5[1]. A lack of knowledge about preventable illness like diarrhea and access to immunization contributes to poor health status of vulnerable families.

PRISMA,  a microfinance institution lending to over 20,000 clients, partnered with IPA to provide microfinance with health education[2].  Freedom from Hunger, an NGO that provides supportive services for the poor, provided guidance to PRISMA in developing an education program based on its worldwide Credit with Education module.

Description of Intervention:

PRISMA village banks were randomly assigned to either a treatment or comparison group. During eight monthly bank meetings, villagers belonging to treatment banks received health education trainings from loan officers, trained by Freedom from Hunger and PRISMA.  The trainings included the following topics focusing on child and maternal health: common childhood illnesses, four danger signals (e.g. diarrhea, cough, fever), medical exams, indicators of quality medical visits, and care for sick children. Surveys administered before and after the trainings collected data on height, weight and hemoglobin ( to measure anemia), days absent from work due to illness, and child nutrition patterns. Institutional outcomes like client retention and repayment rates were also measured.

Results and Policy Lessons:

Adults who received the health education training had significantly higher levels of knowledge of module content than those in the comparison group.   There was no impact on health outcomes for children or institutional outcomes.

Policy Issue:

Health shocks, such as illness or injury, have the potential to cause significant financial strain for low income households, possibly contributing to late payment or default among microcredit borrowers. Insurance could protect households from health shocks, but is unavailable to many in developing countries. High transaction costs and information problems complicate efforts to offer health insurance in a cost-effective way. There is also potential for moral hazard: once clients become insured, they may be less inclined to care for their health. Adverse selection may also occur, as clients predisposed to sickness may be those most willing to purchase insurance, dampening the profitability of insurers. But research has failed to produce a consensus on the impact of adverse selection and moral hazard for insurers in the developing world. How will these impact the market for health insurance? And how will health insurance impact the lives of microcredit clients?

Context of the Evaluation: 

The majority of residents in the Visayas and Northern Mindanao regions of the Philippines live in small towns and rural villages. A large for-profit bank, The Green Bank of Caraga, has been a strong presence in these regions for the past decade. The majority of microfinance clients they service engage in small-scale sales or work as tailors, drivers of local transport, and operators of bakeshops and roadside eateries. Anecdotal information suggests that health shocks are a leading cause of default and drop-out among their clients. Most of the respondents in this study reported that their ability work or do related productive activities was restricted at least some of the time.

Details of the Intervention: 

Researchers worked with the health insurer Philippine Health Insurance Corporation (PhilHealth), which offers the KaSAPI program to help organizations such as microfinance institutions provide affordable health insurance to their members. KaSAPI provided information about the availability and benefits of the insurance to microfinance clients through a marketing campaign. Bank clients were able to use existing savings or loan proceeds to pay for the insurance premium of 300 Philippine Pesos (approximately US$6) per quarter.

Clients were randomly assigned to compulsory insurance, voluntary insurance, or no insurance to serve as a comparison. For clients in the voluntary treatment group, loan officers presented the schedule of PhilHealth benefits and explained that the bank was offering KaSAPI as an optional service for its clients. Premiums were deducted from the loan proceeds. For clients in the compulsory treatment group, loan officers presented PhilHealth materials but also explained that PhilHealth was now a requirement to continue participating in the lending program. Clients’ loans in compulsory PhilHealth treatment group were not released unless they agreed to the premium deduction from their loan proceeds.

End line surveys will establish whether access to health insurance increased risk-taking behavior, if it improved the health status of beneficiaries and if formal insurance crowded out informal insurance arrangements. Evidence will also reveal how health insurance affected institutional outcomes such as profit, client retention, and default.

Context of the Evaluation:

In 2010, the Government of Zambia announced a new national Community Health Worker Strategy that will aim to train 5,000 new CHWs by 2015—a massive investment in a country with only 6,000 nurses. These community health workers will undergo a year of formal training, and will then be posted back to their rural communities, where it is envisioned that they will do most of their work directly within the community, rather than operating from a health facility. The national strategy intends that CHWs will be the first line of health care for Zambians living in the most remote regions of the country.

Before launching the full strategy, the Government of Zambia is implementing a pilot study involving the recruitment, training, and deployment of 315 community health workers across 48 rural districts to examine the most successful methods of recruiting and compensating CHWs.

Description of Intervention:

To examine the selection of community health workers, two recruitment treatments will be used in the pilot study, which will vary in the way in which the job opportunity is framed. In a randomly selected half of the 48 participating districts, recruitment messages will emphasize the “community” benefits of becoming a CHW, such as serving and being a leader in one’s community. In the other half, recruitment efforts will emphasize the “career” benefits of becoming a CHW, such as opportunities for promotion or further professional development. The hypothesis of this experiment is that the recruitment treatments will select for CHWs who possess different characteristics and motivations, and those differences may predict long-term retention and performance. 

Furthermore, in collaboration with the Government of Zambia, researchers are refining a set of incentive schemes that will be tested in order to understand how they affect CHW motivation and performance. It is expected that the final schemes will focus on non-monetary incentives, such as providing CHWs with professional feedback, social recognition, and career advancement opportunities. By randomly allocating the same 48 districts to receive different incentives, the project will be able to test both the overall effects of different reward schemes as well as how the schemes interact with the manner in which CHWs were recruited.

The immediate goal of this study is to provide practical guidance to the Government of Zambia as it prepares to implement the full national CHW strategy. More broadly, this study will give insight to governments and policy makers on how various sources of social recognition (e.g., from government, peers, or the community) and methods of performance feedback (e.g., absolute or relative) can affect the recruitment and motivations of health workers, in ways that potentially predict job performance.

Results and Policy Lessons:

Results forthcoming.

Zambia has one of the world’s highest adult HIV prevalence rates at 14.3 percent. It is estimated that in 2009, 1 million Zambians were living with HIV and 45,000 died of HIV related causes. Although male and female condoms are currently the only protection methods available for HIV, condom use is low and its social acceptability remains problematic. The female condom may be particularly important in the public health community, as it is the only female-controlled tool for HIV/AIDS and other STI prevention. However, like many new technologies, a lack of information about correct use, commonly held misconceptions about the product, and insufficient distribution networks hinder uptake and use of the female condom. This evaluation seeks to investigate the use of hair stylists as private sector channels for the distribution of female condoms.

Description of Intervention:

Researchers partnered with Society for Family Health (SFH) to evaluate their female condom distribution program in Lusaka. SFH’s strategy uses social marketing to promote and distribute health products via community-based agents with connections to the local community. In this case, the community agents were hairdressers and barbers in Lusaka, who were asked to promote female condoms through their shops. Hairstylists were identified as ideal promoters of female condoms both because the familiarity between the stylist and the client creates the potential for successful targeting of female condom to “at risk” customers, and because during the period that a client is in the salon, he or she is a captive audience, allowing the stylist to provide information about the condom.

The study testedthe effect of both financial and non-financial rewards on the selection and performance of agents engaged in promoting female condoms by randomly assigning 1,222 hair stylists to one of four groups:

1. Small financial rewardtreatment - Individuals received ZMK50 (US$0.01) for each condom pack sold.
2. Large financial reward treatment- Individuals received ZMK450 (US$0.09) for each condom pack sold.
3. Non-monetary rewards (Stars) treatment- Individuals received a star for each condom pack sold. Each stylist was provided with a thermometer, akin to those used in charitable fundraisers, which they were instructed to post in a visible location in the salon. Each sale was rewarded with a stamp on the thermometer. In addition, stylists who sold more than 216 packs in a period of one year were invited to a special ceremony at SFH headquarters.
4. Comparison Group- This group received no incentives, financial or otherwise.

Several key features served to identify the effect of different incentive schemes on performance and the underlying mechanisms: (1) Information was collected on all agents who could have applied for the job, to test whether different incentive contracts attract different agents type; (2) Agents’ performance was measured monthly over a one year horizon, to test whether changes in behavior may be due to a novelty effect; and (3) A modified altruism (dictator) game yielded direct and quantitative measure of the agents’ motivation for the cause, and tested whether financial incentives reduced performance by crowding out intrinsic motivation.

Results:

Condom Sales:Non-financial incentives were the most effective at generating female condom sales. Hair stylists in the “star” treatment sold twice as many packs of condoms (14 vs 7) as agents in any other group. In other words, the likelihood of selling at least one pack was 12 percentage points higher for agents in the star treatment; this represents a 33 percent increase over the mean of the control group. Agents in the high and low financial reward treatments, in contrast, were not more likely to sell at least one pack than agents in the control group. However, the sales levels overall were generally low. Even in the star treatment, the average promoter sold slightly more than one pack per month.

Mechanisms of impact: Further analysis indicates that the non-financial incentives operated through two channels. First, non-financial incentives seemed to leverage intrinsic motivation for the cause - they were more than twice as effective for stylists who are motivated by the cause, as measured both by their donation in the altruism game and by personal characteristics correlated with motivation. Second, non-financial incentives appear to have facilitated social comparison among stylists - the impact of the incentives increased with the number of neighboring salons that received the same treatment.

Contrary to existing evidence, researchers found no evidence that financial incentives crowded out intrinsic motivation. On the contrary, high financial rewards were more effective for agents who scored higher on our motivation measure.

Sierra Leone’s health indicators are among the lowest in the world, and the country’s health system is plagued by such chronic worker absenteeism, resulting in part from a lack of accountability between service providers and patients, and the weak incentives healthworkers face. Alongside a national decentralization program introduced in 2004, the Government of Sierra Leone launched an ambitious policy in 2010 to institute free healthcare for pregnant women, new mothers and children under-five. The policy abolished user fees, while at the same time raising workers’ salaries. However, these reforms occurred without introducing institutional features to improve oversight of health workers or changing underlying incentive systems, leaving the health sector at risk of further weakening in response to rising demand for free health services.

Details of the Intervention:

This project evaluates two social accountability interventions aimed at improving health service delivery via community monitoring and the introduction of an incentive scheme to reward worker performance on the basis of non-financial awards. The 254 clinics taking part in the study have been assigned to participate in either intervention or act as a comparison, with one third of clinics allocated to each group.

The community monitoring intervention introduces health scorecards that provide information regarding the state of health care in each community, and facilitates interface meetings between community members and health facility staff. During these meetings, information about the state of healthcare is disseminated via a community scorecard and mutual commitments are made to improve services through a joint action plan addressing areas such as staff absenteeism, maternal mortality and vaccination rates. This framework aims to ensure participatory decision-making and hold both healthcare workers and the community mutually accountable, fostering increased access to and utilization of maternal and child health services. Researchers evaluate whether service quality and quantity improve due to the lower costs of collective action introduced through these meetings and the social accountability contract.  

The second intervention, non-financial incentives,facilitates a yardstick competition among groups of maternal and child health clinics, and rewards workers at the most improved facilities. The relative rankings of clinics on key measures of such as worker absenteeism, staff attitude and charging of illegal fees will be advertised publicly, and staff at winning clinics will receive letters of commendation from high-ranking politicians, and an award at a public ceremony.

The project is being conducted in partnership with the Government of Sierra Leone and the interventions have been designed with a self-sustainable model for scale-up through the Ministry of Health and Sanitation in mind. Researchers will assess the cost-effectiveness of each intervention, as well as their cost-effectiveness relative to one another, and findings will directly inform the government’s decision to scale up these interventions in future years.

Results:

Results forthcoming

Policy Issue:

The vast majority of HIV cases occur in sub-Saharan Africa, where nearly 2 million people become infected with HIV/AIDS every year. One quarter of these new HIV infections are among people under 25, and almost all are due to unprotected sex.  AIDS is incurable and no successful AIDS vaccine has been developed. Ensuring the adoption of safer sexual behavior among youth is critical to preventing the transmission of this disease. However, there is surprisingly little evidence concerning the relative effectiveness of different programs to reduce risky sexual behavior.

Context:

Kenya has the 10^th largest HIV infected population in the world – nearly 7% of Kenyans are infected.[i] Children are seen as a “window of hope” in the fight against AIDS, because their sexual patterns are not firmly established. In an effort to prevent HIV infections in new generations, in the late 1990s UNICEF and the Kenya Institute of Education jointly developed an AIDS education curriculum, including student and teacher handbooks. However, by 2003, this curriculum had not been fully implemented, likely due to teacher inexperience and discomfort with talking about this sensitive material.

Description of the Intervention:

This evaluation tested two interventions to reduce risky sexual behavior: training teachers on the existing HIV curriculum, and reducing the costs of schooling by providing free uniforms. The 328 study schools were randomly assigned to one of four groups of about 82 schools. Each of the four groups of schools received a different set of programs:

In groups 1 and 3, three teachers were trained on HIV/AIDS and on how to teach the HIV curriculum. The curriculum covers facts about the disease, and encourages abstinence until marriage and faithfulness afterwards. It also teaches life skills, such as how to say “no” to unwanted or unsafe sexual relations.

In groups 2 and 3, children already enrolled in sixth grade classes were given a free uniform. Implementers also announced that students still enrolled in school the following year would be eligible for a second uniform, and distributed uniforms again the following year.

All in all, group 1 schools received the teacher training program only, group 2 schools received the uniforms program only, group 3 schools received both programs, group 4 received no program at all and thus served as a comparison group.

To evaluate the impact of the two programs on sexual behavior and sexual health, survey data was collected on youths’ sexual behavior. Such survey data can be subject to reporting biases, however. It was therefore important to complement this data with an objective measure of the incidence of unprotected sex, which is the main mode of HIV transmission in Kenya. Two such measures were considered: (1) childbearing rates and (2) STI infection rates. Childbearing rates were monitored regularly between 2003 and 2010. STI infection rates (specifically, Herpes and HIV infection rates) were measured during a long-term follow-up in 2009-2010.

Results:

Impact of Teacher Training only: Training teachers on how to implement the national HIV/AIDS curriculum greatly increased the likelihood that teachers teach about HIV in the classroom. Two years after the training students whose teachers had been trained had greater knowledge about the disease and also reported more tolerant attitudes toward those with AIDS. However, the intervention did not reduce childbearing rates among girls, suggesting that it did not decrease the likelihood that girls engage in unprotected sex. It also did not reduce the risk of STI as measured after 6-7 years.

Impact of Free Uniforms only: Free school uniforms led students to stay enrolled for significantly longer, and reduced the incidence of teen marriage and teen pregnancy. Girls who benefitted from free uniforms were not less likely to have an STI after 6-7 years, however, suggesting that some of the adolescent girls in the free uniforms program, while less likely to engage in committed relationships that lead to pregnancy and marriage, might have engaged in casual relationships.

Combined Impact: In schools that received both free uniforms and teacher training on the HIV/AIDS curriculum, the reduction in drop-outs and teenage pregnancy among girls was lower than that observed in schools that received free uniforms only. This suggests that the curriculum’s emphasis on abstinence until marriage may have persuaded some girls who would have delayed marriage thanks to the free uniforms to instead privilege committed relationships, where pregnancies are more likely. On the other hand, the two programs combined led to a significant reduction in the risk of STI. This suggests that among girls who chose to delay marriage in order to stay in school with the free uniform, the HIV curriculum convinced some to abstain altogether in order to avoid the STI risk associated with casual relationships.

Context of the Evaluation: 

Contaminated water is a leading cause of diarrhea in Zambia, where only 64% of the population has access to safe drinking water sources. Among children under five, 21% have had diarrhea in the past two weeks, regardless of water source or location.³ Many homes in Lusaka, Zambia’s largest city, obtain water from un-sanitized sources. Clorin, an inexpensive chlorine bleach solution used to kill pathogens in drinking water, is a popular product in Zambia to reduce the incidence of water-borne illnesses, and approximately 80% of people have used it at some point. Charging for this effective health intervention could potentially discourage use, but by virtue of having paid for it, it is also possible that people might value the product more, increasing its use. Because it is hard to determine using observational data whether higher prices results in more product usage, or simply deliver the product to those who value it most, an experiment is needed help separate the effects.

Details of the Intervention: 

Researchers present evidence on the effect of prices on product use from a large-scale field experiment. The intervention consisted of a door-to-door sale of Clorin at a randomly chosen, below-market “offer price” to about 1,260 households with poor access to piped water or chlorine home-delivery. Clorin, retailing for about 25 cents, is inexpensive so as not to discourage use based on income. Those who chose to buy the product were then offered a randomly chosen discount, allowing for a varied “transaction price”. Researchers returned to those households and conducted a follow-up survey and chemical water test to determine how often Clorin was used.  

Screening and Sunk Cost Effect:Researchers sought to find whether higher prices can help target those who would most use the product (screening effect) by seeing if, as the offer price rose, those who chose to buy Clorin had higher usage, implying higher expected benefits. Researchers also sought to determine whether higher prices resulted in a higher propensity to use (sunk cost effect). Assuming households incur a higher psychological cost if they do not use a product they have paid more for, they will be likely to use Clorin if the price was increased. Therefore, for a given offer price, a higher transaction price could lead to a stronger desire to rationalize one’s purchase through use.

Results and Policy Lessons: 

Impact on Clorin Use:Researchers found that fewer people bought Clorin as the price rose; for every 1% increase in price there was a 0.67% decrease in quantity demanded. However higher prices did appear to screen out those who would not have used the product in any event, and a higher willingness to pay was associated with greater propensity to use. As the offer price increased by 10%, use increased by 4% on average among those who did buy the Clorin. No sunk cost effect was observed.

Overall, the use of chlorine does decrease with higher prices due to dampened demand, but this decline is partially offset by better targeting of the product to families who are likely to use it. Significantly, there was no evidence that higher offer prices screened out poorer or less educated households.

¹Un/UNICEF, “Water for Life,” http://www.who.int/water_sanitation_health/waterforlife.pdf.
² Disease Control- Priorities Project, “Public Health Significance of Diarrheal Illnesses,” http://www.dcp2.org/pubs/DCP/19/Section/2531.
³ PSI/Zamia, “Society for Family Health: PSI/Zambia,” http://www.psi.org/zambia

Policy Issue: 

Women’s unmet need for contraceptives is commonly explained by three factors: (i) insufficient supply of appropriate contraception; (ii) lack of information or misinformation about those methods; and (iii) restrictive social norms governing fertility control. An alternative hypothesis is that excess fertility reflects the outcome of bargaining between partners with divergent fertility preferences. In many countries men dominate decisions regarding sexual relations and contraception, and spousal discordance may be a prominent factor influencing fertility outcomes.

Context of the Evaluation: 

Zambia currently holds one of the world’s highest maternal mortality ratios, with 729 maternal deaths per 100,000 live births,2 and a similarly high infant mortality ratio with 103 deaths per 1,000 live births.3  Family planning and reproductive health services are not uniformly available throughout the country, and 60% of currently pregnant women in Lusaka report that the pregnancy was unwanted. Although 100% of women reporting unwanted pregnancies report being familiar with at least one method of modern contraception, only 48% have ever used any modern method of contraception, and only 37% currently use modern contraceptives.

Details of the Intervention: 

This study evaluates the effect of male involvement on female contraceptive use through an experiment designed to remove the factors of insufficient supply, lack of information, misinformation, and divergent fertility preferences. Study participants include 1,994 married women who had given birth in the last two years living in compounds serviced by Chipata Clinic in Lusaka.

Women in the study received vouchers that granted appointments with a family planning nurse at the local government clinic, without waiting more than one hour and with guaranteed access to the modern contraceptive method of their choice. An information session explaining all methods of family planning was also given to study participants at the time of voucher distribution. Women were randomized into two treatment groups. In the “individual” arm of the study, women were given these vouchers alone. In the “couples” arm, women were given these vouchers in the presence of their husbands. In all other respects, the experimental protocol in the individual and couples arms was identical.

Results and Policy Lessons: 

Take up of the voucher was high at 47%, indicating that women valued the substantial reduction in the time cost of an appointment associated with the voucher.

However, evidence suggests that sharing information about family planning services with husbands reduces the couple’s propensity to utilize these services. Women who received the voucher in the presence of their husbands were 9 percentage points (18%) less likely to use the voucher to obtain an appointment at a family planning clinic. There is an even larger, 12 percentage point reduction in voucher use for couples where the husband reported wanting more children than the wife. Still a larger reduction in use is reported among younger couples, giving evidence for the hypothesis that differences in future preferences for fertility drive differences in demand for family planning services.

Male knowledge of the voucher led to a substantial reduction in use of these services, suggesting that policies or technologies that shift relative control of contraceptive methods from men to women may significantly increase contraceptive use and reduce average fertility in some contexts. This is important to note given that an increasing number of policymakers have started to promote “male involvement” in family planning. It also suggests that take up of particular modern contraceptive methods may be sensitive to the amount of control women can exercise relative to their husbands in the use of these methods.

1  Partners In Health, “Women’s Health – Reducing maternal mortality, improving reproductive health”, http://www.pih.org/issues/maternal.html. (Accessed September 21, 2009)
2  USAID, “Population, Health and Nutrition Issues in Zambia”,http://www.usaid.gov/zm/population/phn.htm. (Accessed September 21, 2009)
3  UNICEF, “Zambia Statistics”, http://www.unicef.org/infobycountry/zambia_statistics.html. (Accessed September 21, 2009)

Male involvement is a growing trend in reproductive health, but has the potential to do more harm than good if men oppose contraceptive use due to misinformation or personal biases. A past study found that women were less likely to seek family planning services if their husbands were present when the services were offered, implying that unmet need for fertility and excess fertility may reflect underlying differences between partner preferences.  However, because survey responses indicated that family planning was primarily being used for child spacing, rather than controlling total family size, male preferences may be malleable if they are educated on the adverse health effects of bearing multiple children close together without adequate time for the mother’s recovery.

Context of the Evaluation: 

Zambia currently holds one of the world’s highest maternal mortality ratios, with 729 maternal deaths per 100,000 live births,² and a similarly high infant mortality ratio with 92 deaths per 1,000 live births.³ Family planning and reproductive health services are not uniformly available throughout the country, and 60% of currently pregnant women in Lusaka report that the pregnancy was unwanted. Although 100% of women reporting unwanted pregnancies report being familiar with at least one method of modern contraception, including pills, condoms, injectable contraceptives and contraceptive implants, only 48% of women have ever used any modern method of contraception, and only 37% currently use modern contraceptives. This study is a follow-up to a two-year study  in 2007 that found that women were less likely to seek family planning services if their husbands were present when the services were offered.

Details of the Intervention: 

This study will investigate potential avenues to involve male partners in family planning decisions, both by understanding the origins of male preferences and designing educational measures to better inform them about the importance of family planning. By providing information on the increased risk of maternal mortality when a woman has children too close together, this program aims to increase male acceptance of family planning, and therefore improve the ability to involve males in health decisions without risking female health.   

Approximately three-quarters of the couples will be randomly assigned to one of three treatment groups, while the rest will serve as a comparison group. One group of couples will receive information on family planning and maternal health in a one-on-one setting. This will include information on the risk of maternal mortality and morbidity, how it grows with age and number of children, its causes and how family planning can be used to help women by spacing births and reducing family size. A second group will receive this information through community meetings. A third treatment group will receive the information on family planning both one-on-one and in a community meeting. All participants will be asked to sign up for a family planning consultation following the educational session. The comparison group will be asked to answer a survey, and then also be asked to sign up for a family planning counseling session. The participants’ take up of the family planning consultation and subsequent demand of and attitudes toward family planning will be used to measure each intervention’s success. Contraceptive use and fertility outcomes will be monitored through clinic data. Couples will also be surveyed again after one year to measure subsequent fertility and stated preferences for children and for family planning. 

Results and Policy Lessons: 

Results forthcoming.

¹ Partners In Health, “Women’s Health – Reducing maternal mortality, improving reproductive health”, available at http://www.pih.org/issues/maternal.html
² USAID, “Population, Health and Nutrition Issues in Zambia”, available athttp://www.usaid.gov/zm/population/phn.htm.
³ UNICEF, “Zambia Statistics”, available athttp://www.unicef.org/infobycountry/zambia_statistics.html.

Context of the Evaluation: 

Busia district is a poor and densely-settled farming region in western Kenya adjacent to Lake Victoria. Budalangi and Funyula divisions have some of the country’s highest helminth infection rates; upwards of 90% among children aged 6-18. This is in part due to the area’s proximity to Lake Victoria—schistosomiasis is easily contracted through contact with the infected lake water. Other types of helminths can be transmitted through contact with or ingestion of fecal matter. This can occur, for example, if children do not have access to a latrine and instead defecate in the fields near their home or school, areas where they also play.

The prevention and treatment of infectious diseases such as worms is a priority for health officials, and more efficient and sustainable programs could enable the delivery of health care to a larger number of people. Advocates of improving sustainability concentrate on health education, community mobilization and cost-recovery from program beneficiaries to complement the more standard practice of subsidizing health products.

Details of the Intervention: 

This study evaluated the Primary School Deworming Project (PSDP), which was carried out by NGO International Child Support in 75 schools, randomly divided into three groups (1, 2, and 3) and phased into treatment over three years. In each group, a baseline survey was administered to a sample of pupils and all schools with helminth prevalence over 50% were treated with albendazole biannually, while schools with schistosomiasis prevalence over 30% were treated with praziquantel annually.

Cost-Sharing: In 2001, 25 of the 50 Group 1 and Group 2 schools were randomly selected to pay user fees for deworming treatment. Two thirds of the schools participating in cost-sharing received albendazole at a cost of US$0.40 per family, and one third received both albendazole and praziquantel (depending on the local prevalence of schistosomiasis) at a cost of US$1.30 per family. The fee was set on a per-family basis. This introduced within-school variation in the per-child cost of deworming, since households have different numbers of children.

Health Education: In addition to medicine, all treatment schools received regular public health lectures, wall charts on worm prevention and training for two teachers from each school. The lectures and teacher training provided information on worm prevention behaviors—including washing hands before meals, wearing shoes and not swimming in the lake.

Verbal Commitments: A verbal commitment "mobilization" intervention asked people to verbally commit in advance to adopt the deworming drugs.

A questionnaire was conducted in 2001 to test whether households with more “social links” to schools which received early treatment would be more likely to take deworming drugs. Respondents were asked about the friends and relatives they speak with most frequently about child health issues, and the degree of “linkage” to treatment schools was established on this basis.

Results and Policy Lessons: 

Cost-Sharing Intervention:The introduction of a small fee for deworming drugs led to an 80% reduction in treatment rates, consistent with the hypothesis that people have low private valuation for deworming. Take-up dropped sharply when going from a zero price to a positive price, but was not sensitive to the exact price level, suggesting that it may be counter-productive to charge small positive prices for the treatment of infectious diseases.

Health Education & Verbal Commitment Impact:An intensive school health education intervention had no impact on worm prevention behaviors. Child health is likely to be worsened to the extent that funds are diverted from medical treatment into health education in this setting. Asking people in advance whether they planned to take deworming drugs also had no impact on adoption.

Social Learning:Individuals in treatment schools who had more extensive social networks, and therefore presumably had more information about deworming drugs, were significantly less likely to consent to take the drugs. For each additional social link to a family that had already received treatment, a family’s child is 3.1 percentage points less likely to take the drugs, and  these individuals were also more likely to believe the drugs are “not effective.” Negative social effects on take up are especially large for families with more knowledge about deworming, which may be due to overly optimistic prior beliefs about the net private benefits of the drug. A significant portion of deworming benefits flow to others in the local community through positive externalities. The reductions in serious worm infections for untreated students were 70-80% as large as those for treated students, thus while the overall program impact is large, the private benefits of treatment appear only moderate.

Overall, findings suggest that socially desirable health technologies with low private benefits may not spread on their own, due to low private estimations of the benefits which are reinforced through social networks.

Policy Issue: 

Rural to urban migration is a common feature of many developing economies, as people travel to larger cities in search of better employment opportunities. In places where farmers must rely on seasonal crops for their livelihood, seasonal migration away from rural areas can help households increase their income and mitigate the risk inherent in an otherwise agriculture-dependent economy. That some people choose to stay behind and risk famine indicates that there may be barriers to migration, such as credit constraints, lack of information about urban job opportunities, or a desire to remain with local family. Providing incentives for seasonal migration may help identify and overcome these barriers, and mitigate the negative effects that weather patterns can have on rural farmers. Additionally, incentivizing migration to urban labor markets may be a more cost-effective method of overcoming famine than simply providing food aid to the affected areas.

Context of the Evaluation: 

According to the 2005 Bangladesh Household Income and Expenditures Survey, 57 percent of households in the greater Rangpur districts in the Northwest were living below the poverty line compared to 40 percent in Bangladesh as a whole. In this region 43 percent of households experience extreme poverty, defined as individuals who cannot meet the 2100 calorie per day food intake even if they spend their entire incomes on food purchases only. These districts experience seasonal food insecurity, which can often result in famine, known locally as Monga. In Rangpur, Monga is connected to the cultivation of rice, which requires large labor input at planting and harvesting, but almost no work in between. Marginal farmers and agricultural laborers who do not have saved income and cannot find other work experience Monga.

It is common for agricultural laborers in other regions of Bangladesh to either switch to local non-farm labor markets or to migrate to urban informal labor markets in search of higher wages in response to price hikes and wage drops during the pre-harvest season. If he finds work, the laborer can send money back to his family to help alleviate the effects of the pre-harvest lean season. However, this is generally not seen in Rangpur District. A national survey found that 22 percent of all Bangladeshi households receive domestic remittances, while only 5 percent of households in Rangpur reported receiving domestic remittances. This intervention primarily seeks to understand why these Monga-affected workers appear hesitant to seasonally migrate to better employment opportunities.

Details of the Intervention: 

There were two principal interventions: providing information about job opportunities in other locations and providing monetary incentives to migrate.

A subset of households were given information about types of jobs available in other locations, the likelihood of getting each job, and approximate wages for four pre-selected potential migration destinations. A subset of households were offered Tk 800 ($11.50) to migrate either in the form of cash or credit. Tk 600 ($8.50) was given pre-migration and Tk 200 was given once the migrant reported to the research office at his or her destination. A random subset of those receiving a monetary incentive were required to migrate in groups of either 2 or 3 as a condition of receiving money, and a fraction of those groups were chosen by the researchers, while for the rest the households had some choice regarding whom to migrate with. Destinations were also specified for a random subset of the households receiving an incentive, while the rest could choose from a limited set of cities where the researchers had offices and enumerators stationed (to help track the migration experience) and still take advantage of the subsidy.

In total there were 21 treatment groups with different combinations of information, incentives, migration group size, and choice of migration partners or destinations.

Results: 

Incentives: The researchers found that offering an incentive to migrate had a large effect on likelihood of seasonal migration.  Over 40% of households that received a cash or credit incentive migrated, compared to only 14% of households not receiving an incentive.  Providing information about job opportunities but no incentives only increased the likelihood that someone from a household migrated by 3 percentage points. These results suggest that credit or saving constraints reduce migration.

Group Size: Requiring migrants to form groups of three instead of pairs reduced migration probability by almost 6 percentage points. Migrating in larger groups changes the dynamic for the individuals involved with respect to using social networks to find a job and sharing the risks of migration with their partners. When partners are assigned, the larger group reduces propensity to migrate by only 3 percentage points whereas in self-chosen groups, having to form larger group reduces propensity to migrate by almost 9 percentage points. This suggests that people may have trouble forming groups and finding the right set of partners with whom to migrate.

Migration Location: Placing restrictions on a migrant's destination decreased take-up of the migration incentive by 7.4 percentage points. The distance to the destination also appears to be an important consideration. For example, when faced with the option of migrating to two similar sized cities with comparable market opportunities, households were 12 percentage points were likely to migrate to the closer city. However, the size of the labor market is even more important: migrants are 6 percentage points more likely to take-up the offer when Dhaka is specified as the destination compared to when a nearby smaller town, Munshiganj, is offered.

Further analysis will provide more evidence on the key determinants of the migration decision as well as the longer-term effects of seasonal migration.

Researchers sought to find an inexpensive way to improve water quality at the source, and thereby reduce the burden of diarrhea by making improvements to springs. Working with a local NGO, they identified 200 springs in the Busia district of Kenya, and persuaded each local community to contribute 10% of the costs to improving the springs. At a cost of about $1,000 per site, half of these springs had their sources encased in concrete, forcing water to flow through a pipe rather than seeping from the ground, thus preventing contamination from groundwater.

Results:

The simple infrastructure investment of “spring cleaning” significantly reduced both water contamination and the incidence of diarrhea. There was 66% less E-coli contamination in treated springs than in untreated ones, and diarrheal incidence in children under 3 years old fell by 4.7 percentage points, or 25%, though there was no significant effect on children ages 5 to 12.

Context of the Evaluation: 

Like other developing nations in the region, iron deficiency anemia and Vitamin A deficiency affect many of India’s children. Over 69% of preschool aged children in urban Delhi are anemic and 30% suffer from intestinal worms, contributing to the high prevalence of malnutrition. In 2005, 46% of children were found to be underweight, and 38% were found to have stunted growth. Children in this study typically came from families of poor migrant laborers, and have a particularly high risk of anemia and other nutritional deficiencies.

Details of the Intervention: 

This study evaluated the impact of NGO Pratham’s preschool nutrition and health project in the slums of Delhi, India. The program delivered a package consisting of iron and Vitamin A supplementation and deworming drugs to 2-6 year old children through an existing preschool network.

Two hundred preschools with a total of 2,392 children were randomly divided into three treatment groups, which were gradually phased into the program over two years. The deworming drugs were taken at “health camps” held at the preschool approximately every three months. Preschool teachers in treatment schools were instructed to administer daily iron doses for thirty school days following each health camp. Children in both treatment and comparison groups were also administered Vitamin A supplements, which in addition to other health benefits, promotes the absorption of iron.

Results and Policy Lessons: 

Child Weight Gain: Large gains in child weight—roughly 0.5 kg on average—were found in the treatment schools relative to comparison schools over the two-year study period. No gains in average child height were found, but this pattern makes sense from a clinical standpoint: iron supplementation is thought to reduce acute malnutrition in the short-run by improving the absorption of micronutrients and increasing appetite, but improvements in chronic malnutrition are not expected over short periods.

Impact on School Attendance: Average preschool participation rates increased sharply by 5.8 percentage points among treated children, reducing preschool absenteeism by roughly one fifth.

Given the low cost of the intervention (averaging approximately US$1.70 per additional year of schooling induced for one child), these results suggest that the package of iron, Vitamin A and deworming drugs is a highly cost-effective means of improving child school participation and health in a poor urban setting where anemia and worm infections are widespread.

Researchers sought to examine how varying the price, distribution, and promotion of the chlorination products affected a household’s willingness to pay and rate of use. Households were given seven WaterGuard bottles, an individual water treatment product, each sufficient for one month’s supply of clean water. One third of this group received coupons for a 50% discount on future purchases of WaterGuard bottles, one third received additional verbal persuasion messages beyond the basic WaterGuard instructions, and another third received no additional coupons or messages. To estimate social networking effects, the free WaterGuard bottles were distributed in different percentages in each community.

Results:

After receiving a free 7-month supply, chlorine was detected in 58% of households, much more than the 2% starting level but only 10% of the distributed coupons were redeemed. Dispensing free chlorination dispensed at water sources along with community promoters provided the most effective strategy to improve water cleanliness, suggesting that similar programs may help prevent diarrheal incidence in areas such as rural Kenya.

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. 

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.