The Hunger Project's "Epicenter" Scale up Strategy in Ghana

One of the greatest tragedies of extreme poverty is its intergenerational transmission. Poor, malnourished children do not develop normally, physically or cognitively; poor adolescents are unable to take proper advantage of educational opportunities and are more likely to engage in risky behaviors.  After generations of poverty, many families and communities cannot envision cooperation to break this cycle. The Hunger Project (THP) works towards tackling poverty in Africa by partnering with local people to establish community centers ("epicenters") offering a comprehensive range of services, from health and education, to agriculture, microfinance, water and sanitation, as well as fostering community spirit. This randomized evaluation of THP's multi-faceted program aims to assess the impact on the various outcomes it strives to improve.

Researchers from Yale University and IPA have partnered with THP to evaluate the long term-impact of this strategy on health, nutrition, income, gender roles, social cohesion and education. The Hunger Project plans to cover the entire Eastern Region of Ghana, however it is neither feasible nor desirable to build all 112 centers at once. A lottery is conducted within each district to determine which of the 112 communities are offered a center in the first years (treatment group).  Communities that do not win the lottery for early invitation, the comparison group, may receive an invitation a few years later.  A pre-intervention baseline survey of approximately 4000 households with over 20,000 individuals was completed in 2008 and a follow-up survey of the same households will be launched in early 2013.  The longitudinal nature of the survey allows us to examine if the effects of the centers are sustained over time and whether or not the strategy is financially sustainable. Generally, these centers aim to be economically sustainable within 5 years.

Saving for Health Expenditures in Kenya

Health remains a major barrier to economic development in poor rural areas. Access to effective health products, whether preventive or curative, has so far remained limited due in large part to poverty and the absence of financial markets that would enable poor households to invest in health on credit. Given such constraints, poor households should save in anticipation of future health shocks. However, substantial evidence suggests that they lack adequate savings products, and, as a result, households are quite vulnerable to health shocks. In order to afford medical expenditures, they resort to drawing down productive assets or business capital or to other costly risk-coping strategies.

Policy Issue

The benefits of investing in health are thought to be very high. For example, it has been estimated that 63 percent of under-5 mortality could be averted if households invested in preventative health products. Despite this, investment levels remain quite low in many developing countries. While many people point to credit constraints as the primary impediment, barriers to savings also appear to be a significant obstacle to investing in health. There are several major pathways through which savings may be constrained. Inter-household barriers may be relevant if social norms that necessitate that an individual provide support to friends and relatives if she is asked and has the cash on hand. Intra-household barriers may arise if members of a household have different spending preferences. Intra-personal barriers may arise if an individual’s saving and spending preferences are not constant over time. It is necessary to better understand these pathways and their relative importance so that we may develop more efficient health saving devices.

Context of the Evaluation

The researchers chose to work with a common social structure in the area: a ROSCA (Rotating Saving and Credit Association) - a group of individuals who make regular cyclical contribution to a fund, which is then given as a lump sump to a different member at each meeting. Recent studies reveal very high participation rates in these organizations; across Sub-Saharan Africa, average membership among adults ranges between 50 and 95 percent.i

Details of the Intervention

To estimate the relative importance of the different types of barriers to savings, the researchers randomly varied access to a set of saving devices specifically designed to alleviate one or more of the barriers discussed above. One hundred and thirteen ROSCAs were randomly assigned to five groups: four of the groups were given specific savings devices to use in addition to their regular weekly savings, while the fifth group served as a comparison.

In the first two treatment groups, members of the ROSCAs were given a locked metal box (with an opening in which deposits could be made) in which they could save at home. In the first group – the “Safe Box” group – members were given the key to the lock and could therefore take money from the box whenever they wanted, even to spend on non-health products. In the second group – the “Lock Box” group – members were not given the key and had to call the program officer in order to open the box. Once opened, the money in the box could only be used to buy health products.

The other two treatments were at the ROSCA level. In the third treatment group, individuals were encouraged to use their existing ROSCA to create a “Health Pot” in which members would contribute an additional amount during regular meetings earmarked for health products only. In the fourth group, individuals were encouraged to save in an individual “Health Savings Account” (HSA) that would be held at the ROSCA and earmarked for emergency health costs only (i.e. respondents were only allowed to withdraw this money if they needed it for a health emergency).

In all five groups, participants were encouraged to save for health savings goals. Thus, any effect of a savings product above and beyond the control group should be attributable to the product itself.

Results and Policy Lessons

Overall, the results indicate a significant demand for such savings products. Take-up of all four treatments was extremely high, suggesting that the primary effect of all treatments is simply the provision of a mechanism to protect money from others. 

In terms of health impacts, the researchers looked at two outcomes: (1) how much people invested in preventative health in the year following the program; and (2) whether people had enough money to deal with health emergencies. Note that the Lock Box and Health Pot were geared towards outcome (1), the Health Savings Account was geared towards outcome (2), and the Safe Box was geared to both outcomes.

Investments in Preventative Health: A year after the intervention, individuals in the Safe Box andHealth Pot groups had significantly higher levels of investments in preventative health products than those in the comparison group. Relative to comparison group individuals, the Safe Boxincreased investment by 67 percent, while the Health Pot increased investment by 128 percent. As expected, the Health Savings Account had no effect on this measure. Surprisingly, however, the Lock Box had no effect either. This lack of an effect is because the value of tying up money towards health is outweighed by the cost of completely limiting liquidity (for instance, to deal with unexpected income shocks). 

Coping with Health Shocks: Individuals in the Health Savings Account treatment were less vulnerable to unexpected emergencies. People in the Safe Box group also appeared somewhat less vulnerable, though the effects were not significant at conventional levels. As expected, there was no effect in risk coping in the two treatments groups that were not designed for emergency savings.

Prevalence of Savings Barriers: The results confirm the presence of all three types of savings barriers. First, inter-personal barriers are substantial - those who were previously giving assistance to others without receiving assistance in return benefited more than others. Second, intra-personal barriers also matter. Those whose savings preferences were not constant over time (as measured by survey questions) were not able to benefit from the Safe Box (because it was too easy for them to access the money). They also did not benefit from the Lock Box – this is because even though the savings in the box was illiquid, there wasn’t a strong incentive to actually put money into the box in the first place. However, they did benefit from the stronger commitment and social pressure to make deposits that was provided by the Health Pot. Third, there is some evidence of intra-household barriers. The effects of several of the interventions were larger (though not statistically significantly so) for married individuals. 

 

i Anderson, Siwan and Jean-Marie Baland. 2002. “Economics of Roscas and Intrahousehold Resource Allocation.” The Quarterly Journal of Economics 117 (3): 963-995

    Primary School Deworming in Kenya

    Hundreds of millions of children worldwide are infected with parasitic worms. These worms are detrimental to children's health, their cognitive development, their education and their futures. Chronic illness caused by worm infections reduces literacy and adult productivity. 

    Free deworming treatment substantially improved student attendance and health. The program also had significant "spillover" effects, improving health outcomes and attendance among students in neighboring primary schools. 

    Including the spillover benefits of treatment, the cost of keeping a child in school one additional day is only US$0.02, which makes deworming considerably less expensive than any alternative method of increasing primary school participation.

    Given the great success of this project, IPA is now working to Scale Up school-based deworming in partnership with Deworm the World.

    <--break->Policy Issue

    Intestinal helminths—including hookworm, roundworm, schistosomiasis and whipworm—infect more than one in four people worldwide and are particularly prevalent among school-aged children in developing countries. These intestinal worms are believed to have a negative impact on education, hindering child development as well as school attendance and reducing income later in life. These effects are especially pronounced in Africa, where nearly half of the total disease burden is due to infectious and parasitic diseases, including helminth infections. Existing randomized studies have focused primarily on the effects that these diseases have on cognitive performance, whereas outcomes of more direct interest to economists and policymakers—school attendance and enrollment, test scores, and ultimately, labor market outcomes—have yet to be thoroughly investigated.

    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, in part due to the area’s proximity to Lake Victoria—schistosomiasis is easily contracted through contact with the contaminated lake water. Soil-transmitted helminths (STH), on the other hand, are 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, where they also play. One quarter of Kenyan student absenteeism is attributed to abdominal pains which likely due to intestinal helminth infections. In addition, older children may miss school to take care of siblings who are sick with helminth infections.

    Details of the Intervention

    This study evaluated the Primary School Deworming Project (PSDP), which was carried out by International Child Support in cooperation with the Busia District Ministry of Health. The program randomly divided 75 schools into three equal groups which were phased into treatment over three years.

    Within each group, a baseline parasitological survey was administered to a random sample of pupils. Schools with worm prevalence over 50% were mass treated with deworming drugs every six months. Girls of reproductive age (thirteen and older) were not supposed to be treated due to concerns about the possibility of birth defects. Nonetheless, 19% of girls thirteen and older also received medical treatment, partly due to confusion about pupil age, and partly because several Kenyan public health nurses administered drugs to some older girls, judging the benefits to outweigh the risks. In addition to medicine, treatment schools received regular public health lectures, wall charts on worm prevention, and training for one designated teacher. The lectures and teacher training provided information on worm prevention behaviors—including washing hands before meals, wearing shoes and not swimming in the lake.

    Results and Policy Lessons:

    Impact on Infection Intensity: Deworming reduced serious worm infections by half amongst children in the treatment groups. Pupils that received treatment reported being sick significantly less often, had lower rates of severe anemia, and showed substantial height gains, averaging 0.5 centimeters.

    Impact on School Attendance: Deworming increased school participation by at least 7 percentage points, which equates to a one-quarter reduction in school absenteeism. When younger children were dewormed, they attended school 15 more days per year, while older children attended approximately 10 more school days per year. The larger impact of treatment in lower grades may partially result from higher rates of infection among younger pupils.

    Treatment Spillover: The entire community and those living up to 6 kilometers away from treatment schools benefited from “spillovers” of the deworming treatment. Spillover effects occur because medical treatment reduces the transmission of infections to other community members. Reductions in infection in non-treated children resulted in an additional 3 to 4 days of schooling per year. Although data was not collected on adults, it is also likely that older community members were able to work more days as a result of spillover effects.

    No improvements in test scores were found as a result of the deworming. Additionally, evidence suggests that health education had a minimal impact on behavior, so that to the extent that the program improved health, it almost certainly did so through the effect of the medicines rather than through health education. Including the spillover benefits of treatment, the cost per additional year of school participation is US$3.27, considerably less than the cost of many alternative methods of increasing primary school participation.

     

    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.org, 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

    Impact of Malaria Education on the Health of Microfinance Clients in Benin

    In countries like Benin, where the rural population suffers from poor health, health education is often viewed as a needed compliment to microcredit, as illness can prevent borrowers from repaying their loans. In this study, researchers partner with non-profit Freedom from Hunger and a microfinance institution in Benin to evaluate the impact on health and social outcomes of integrating health education into female only or mixed-gender group microcredit meetings.

    Policy Issue:
    Just as illness can keep a person from working or going to school, it can also cause microfinance recipients to fall back or default on loan payments. In some cases loan defaults are linked to illness, which consumes available cash and makes the victim unable to work. Community organizations and policy makers have therefore proposed including health education alongside microfinance services. As a complement to microfinance services, health education could potentially increase repayment rates for the microfinance institution (MFI), while also improving the lives of clients. Health education increases costs for MFIs, who must direct resources towards training loan officers as educators, and increase the time that loan officers spend at each village banking meeting where training is given. There is potential for benefit on measures of both health and microfinance outcomes, but if the additional trainings are ineffective, they could be drawing away an MFI’s resources away from its core activities.
     
     
    Context of evaluation:
    Located in West Africa, Benin’s economy is based primarily on agriculture and regional trade. The rural population in Benin suffers from very poor health. Although WHO estimates suggest that 20% of children in Benin under the age of 5 sleep under insecticide treated bed nets – a proven defense against malaria contraction -  27% of deaths in children under 5 are nonetheless attributed to malaria.  There are a number of MFIs in Benin, and PADME represents a significant share of the market, serving approximately 44,000 borrowers out of an estimated 140,000 in the entire country.[1]

     
    Description of Intervention:
    In 2006, Freedom from Hunger launched the Microfinance and Health Protection (MAHP) initiative in rural Benin to help local MFI partners create and sustain key health services that complement their credit offering. This evaluation seeks to test the impact of providing credit with education on health and microfinance indicators, as well as the impact of combining education with the provision of health care products, and the specific aspects of the solidarity lending design.
     
    In Benin, researchers will work with PADME to introduce the health education intervention to half of the villages they serve.  PADME typically markets their services by reaching out both to community leaders and individuals who may be interested in taking out loans, which vary in size with an average amount of nearly $1000 US.[2]  In the villages randomly assigned to receive the intervention, clients will be offered access to credit as well as health education.  In the comparison villages, potential clients will only be offered access to credit.  . The health education will consist of three modules: malaria education, integrated management of childhood diseases, and HIV/AIDS planning. An additional component of the study seeks to better understand the role of gender in microfinance.  In addition to the random assignment of health education services, researchers will also designate villages according to the gender composition of new borrowing groups.   In a random subset of villages, microfinance groups will be mixed-gender, while others will be female only.
     
    Results and Policy Lessons:
    Results forthcoming.


    [2] http://www.accion.org/Page.aspx?pid=659

    Credit with Health Insurance: Evidence from the Philippines

    The addition of health insurance to microcredit products is increasingly popular; but is it sustainable for microfinance institutions? This study complements other IPA research on hospitalization insurance in the Philippines and should provide important policy lessons on providing public services. We partner with Green Bank to evaluate the impact of providing access to the national health insurance program (PhilHealth) among microfinance clients.  Anecdotal evidence from Green Bank field staff suggests that illness among clients and their families is one of the biggest causes of delinquency.  The PhilHealth program offers an opportunity to reduce clients' vulnerability to unexpected health shocks. 

    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.
     
    Results and Policy Lessons:
    Results forthcoming. 

    Commitment Savings Accounts and Quitting Smoking in the Philippines

    Can financial incentives work to help people quit smoking?  The CARES (Committed Action to Reduce and End Smoking) Program, creates a commitment contract that provides financial incentives for smokers who wish to quit smoking. Smokers offered the product were more likely to be smoke-free 6 and 12 months afterwards.

    Policy Issue: 

    Despite detrimental effects, people throughout the world habitually engage in damaging or inefficient habits such as smoking, eating poorly, or failing to save money. Experts believe that this is because people’s preferences change over time: in the long-run an individual may wish to quit smoking, for example, but in the moment their preference for a cigarette may outweigh their desire to quit. Such behavior, known as time inconsistent preferences, may help to explain why people make inefficient choices that result in poor health or a lack of financial cushioning. Some researchers theorize that habits that have negative long-term effects can be discouraged by giving people commitment devices: contracts which constrain their future behavior, and may exact a financial penalty if they revert to bad habits. 

    Context of the Evaluation: 

    Despite its serious health effects, smoking is extremely commonplace in the Philippines: in 2009, 28.3 percent of Filipinos aged 15 years or older were current smokers, and 22.5 percent smoked on a daily basis. Smoking is also a considerable expense, with the average surveyed smoker spending approximately 100 pesos (US$2) per week on cigarettes, nearly 15 percent of their monthly income. Even though it is a common behavior, 72 percent of survey respondents reported that they wanted to stop smoking at some point in their life, and nearly 45 percent indicated that they had tried to stop smoking within the last year. Survey responses suggest that their lack of success may be due to time inconsistent preferences: though 72 percent reported that they wanted to stop smoking at some point, only about 18 percent of people said that they wanted to stop smoking now. 

    Details of the Intervention: 

    Committed Action to Reduce and End Smoking (“CARES”) is a voluntary commitment savings program. The basic design of the product allows a smoker to deposit a self-selected amount of his own money that will be forfeited unless he passes a biochemical test of smoking cessation. To enroll people in the CARES program, the Green Bank of Caraga identified regular smokers off the street and asked them if they wanted to participate in a short survey on smoking. All subjects received an informational pamphlet on the dangers of smoking, and a tip sheet on how to quit. After completing this baseline survey, subjects were randomly assigned to receive one of four offers:

    1. CARES with deposit collection: A minimum balance of 50 pesos (about US$1) was required to open a CARES account, and individuals were encouraged by marketers to deposit the money they would normally spend on cigarettes into this account each week. This group also received weekly visits from deposit collectors, saving them the weekly trip to the bank. All CARES clients were able to deposit into, but not to withdraw from these accounts, and the accounts yielded no interest, to discourage non-smokers people from using them as a substitute for normal savings accounts. 
    2. CARES without deposit collection: Same as above, except these clients had to go to a bank branch themselves to make deposits.
    3. Cue Cards: These individuals got to choose from among four wallet-sized cards depicting negative health consequences of smoking: premature babies, bad teeth, black lung, or a child hooked up to a respirator. They were encouraged by the marketers to keep them in a prominent location. 
    4. Comparison Group: These individuals received no additional information. 

    Six months after the baseline survey, all survey respondents took a urine test to determine if they were still smoking. Individuals in the CARES treatment groups would receive their entire balance back if they passed the test, but would forfeit it if they failed or refused to take the test. Non-clients (those assigned to the cues and comparison groups) were paid 30 pesos (US$0.60) for taking the six-month test, and all respondents were paid 30 pesos for taking another test 12 months after the baseline. 

    Results and Policy Lessons: 

    In total, about 11 percent of individuals who were offered CARES signed a contract. Individuals who reported wanting to quit, who were optimistic about quitting, and who already exhibited strategic behavior to manage their cravings (i.e. avoiding situations that made them want to smoke) were more likely to sign a contract. On the other hand, individuals who reported wanting to quite more than a year in the future, and who showed signs of being heavy smokers were less likely to sign a contract. Ninety percent of CARES clients opened with the minimum amount of 50 pesos, and 80 percent made additional contributions. The average client contributed about every two weeks, and after six months had a final balance of around 553 pesos, equal to approximately six months’ worth of cigarette spending.

    Individuals who were offered a CARES contract were 3.3 to 5.8 percentage points more likely to pass a urine test for nicotine after six months than those in the comparison group, and were 3.4 to 5.7 percentage points more likely to pass after 12 months—a substantial effect considering that only 8.9 to 14.7 percent of comparison individuals passed the test. This represents an over 35 percent increase in the likelihood of smoking cessation compared to baseline.  However, despite these large treatment effects, a surprisingly large proportion (66 percent) of smokers who voluntarily committed to CARES ended up failing to quit. Still, the results of the CARES program were far above the reductions in smoking associated with the cue card treatment, which had no effect on smoking cessation: though over 99 percent of clients offered the cue cards accepted them, fewer than half remembered the cards and knew where they had put them one year later, and only about 5 percent reported still using them to manage cravings. However, it is still not known how much of the CARES treatment effect was due to the financial commitment that all clients made, and how much was due to the frequent contact that some clients had with deposit collectors. 

     

    Selected Media Coverage:
    Sticking to It - Project Syndicate
     

    Health Education for Microcredit Clients in Peru

    Policy Issue:

    Health and education are areas affected by poverty.  Households with limited resources face barriers affording quality education and seeking access to health information.  As microfinance has become a popular development tool, its services have expanded to address other issues associated with poverty.   Credit with Education is one model that provides microfinance clients with training services. By simultaneously addressing needs for financial services and health information, these programs attempt to create synergistic positive effects on clients and their families.

    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 the 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.



    [1]World Health Organization, “Peru,” http://www.who.int/countries/per/en/.

    [2]Prisma, “Microfinanzas, ” http://www.prisma.org.pe/#cabecera.

    Demand for Hospital Insurance in the Philippines

    We partner with Green Bank to assess the demand for hospital insurance among microfinance clients.  Green Bank offered the insurance to clients at randomly assigned premiums.  By observing the take-up rates at different prices, we can measure the price sensitivity.   We also collect an extensive data on demographics and risk characteristics of the individuals in the sample, which allows for an examination of adverse selection in the insurance market (risky individuals are less price sensitive than risk-adverse individuals).

    The impact of information asymmetries on insurance markets is important in theory but ambiguous in practice.  Generations of studies have failed to produce a consensus on the presence, absence, or magnitude of adverse selection and moral hazard in most markets.   While an increasing number of microfinance institutions offer insurance products to their clients as an add-on, there are few empirical studies on the impact of expanding access to health or hospitalization insurance in developing country contexts.

    The sample of our study includes 2,036 existing clients under the Green Bank's individual-lending program (TREES) in 10 branches of Northern Mindanao and Caraga regions. 

    The Socio-economic Impacts of Ebola on Households in Sierra Leone

    The economic impacts of the Ebola virus must be monitored in real time for policymakers to estimate the short- and long-term costs of the epidemic and respond appropriately, yet information on the magnitude of the effects remains scarce. The aim of this monthly survey in Sierra Leone is to measure the economic and social impacts of the outbreak on households and provide timely updates on the survey's findings to policymakers.

    Policy Issue:

    The Ebola outbreak in West Africa may be disrupting local economies, and if so, the long-term impact could be considerable. Reports have circulated that the virus has increased prices, reduced the availability of essential goods, and impacted agricultural production, yet there is little to no quantitative data to back these claims and inform appropriate policy responses. There is a great need, therefore, to monitor economic impacts in real time and provide accurate date to governments and their development partners. This research in Sierra Leone aims to help fill the information gap and supply policymakers with timely updates to address the crisis in both the short- and long-term.

    Note: This is not a randomized controlled trial.

    Context of the Evaluation:

    Since its initial appearance in March 2014 in rural Guinea, the Ebola virus has spread to three other West African countries.  As of November 12, 2014, Sierra Leone has had more than 4,900 confirmed cases and nearly 1,200 deaths.1 The situation has become even more challenging as the virus has now taken hold in the capital, Freetown. Two of the country’s fourteen districts have been quarantined for over two months, an additional three districts were quarantined in mid-September, and certain areas of the capital are also under isolation. 

    In partnership with the World Bank, IPA is supporting Statistics Sierra Leone (SSL) with on-the-ground technical assistance and supervision for a monthly household survey that measures the economic impacts of the Ebola virus over time.

    Details of the Intervention:

    This multi-round survey is a tool for monitoring the socio-economic and service delivery impacts of the Ebola virus. IPA and Statistics Sierra Leone will jointly administer the cell phone survey to a subsample of households taken from a national survey. The focus of the data collection is on economic indicators – such as the functioning of labor markets, the availability of foodstuffs, agricultural production, other health outcomes.

    We aim to conduct a 20-minute survey at monthly intervals, with some questions  administered every month and other questions rotated into the questionnaire based on the situation at the time. 

    The questionnaire will incorporate baseline information from the nationally-representative Labor Force Survey (SLLFS), administered in 2014, to capture changes and, due to the brief nature of this survey, to target and streamline data collection.

    Results and Policy Lessons:

    Results forthcoming.

     


    [1] Source: CDC Ebola Outbreak Monitoring, http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/index.html

    The Impact of Ebola on Market Prices in Sierra Leone

    Starting the summer of 2014, many risk factors pointed to a potential food crisis in areas of West Africa hit hardest by the Ebola outbreak. Innovations for Poverty Action, in partnership with researchers and the International Growth Center, began monitoring markets across Sierra Leone for changes in food prices and supply. Researchers are now providing rapid feedback to the government and other development partners on where food shortages are occurring. With our partners, we are continuing to monitor food markets across Sierra Leone.

    Policy Issue:

    The Government of Sierra Leone and its development partners must have valid, credible data and analysis to ensure that their policy responses to the Ebola outbreak are evidence-based and well targeted.While many reports are circulating about the outbreak’s effects on the economies of affected countries, hard data on what is happening on the ground is in short supply. Some communities have been quarantined under a “cordon sanitaire,” potentially affecting food prices and supply in these areas. A slowdown in agricultural production, local and international trade, and/or labor supply could also be impacting food security. By tracking food prices and the supply of staple foods in markets countrywide, this research aims to identify food insecurity before it happens and provide rapid feedback to the government.

    Note: This is not a randomized controlled trial.

    Context of the Evaluation:

    To help contain the Ebola outbreak, the Government of Sierra Leone has restricted movement in and out of certain areas of Sierra Leone. The quarantine of certain areas under the cordon sanitaire was imposed around the towns of Kenema and Kailahun in the summer of 2014, and expanded to other areas in September. This cordon could be obstructing the movement and marketing of food and causing spikes in food prices.

    Details of the Intervention:

    Researchers are measuring the impact of the Ebola outbreak on market prices in Sierra Leone. IPA is gathering data from markets across the country, and researchers are measuring changes over time and comparing the information to similar data we gathered from the same markets in 2011 and 2012.

    In mid-August we collected data from 153 markets on food availability, prices of key food stuffs (including imported and domestic rice, cassava, palm oil, and fish), and the number of traders operating in the market. We then conducted a second round of market surveys during mid-September in 157 markets.

    IPA staff based in Freetown surveyed individuals by phone that manage markets across the country. (We gathered the phone numbers in 2011 and 2012 during a previous survey.)

    Using data from previous surveys, we have been able to compare these prices to those at the same time of year in 2012 and, for most markets, in 2011. Because we have the GPS location of the markets it has also been possible to compare outcomes for areas badly hit with Ebola or subject to transport restrictions, such as closure of borders, with those that have been relatively Ebola-free and not subject to transport restrictions.

    Collecting data every month during the course of the outbreak is allowing researchers to track shortages pre-harvest and potential surpluses post-harvest (which may accumulate if transport is disrupted and drive prices down in some areas).

    The latest round of market surveys took place in early October shortly after all Sierra Leoneans were asked to stay at home for two days and after the introduction of new cordon restrictions in Port Loko, Moyamba, and Bombali.

    Results and Policy Lessons:

    Data collected in August and September revealed that prices were relatively stable. While new evidence from October reveals prices of basic food commodities are not significantly higher than they were in recent years, some findings suggest the situation is worsening:

    The number of traders selling basic food items has continued to fall in all districts. In Kailahun and Kenema (the first districts to be cordoned) there are 69 percent fewer domestic rice traders than in 2012 while the decline in newly cordoned areas is 29 percent. Other key findings from October 2014:

    •    Prices of basic food commodities at markets were not significantly higher in October than they were at that time in previous years, nor were they higher on average in cordon areas.

    •    There were outliers where prices were much higher and there were more of these outliers than in normal years.

    •    There was an increasing number of markets that are closed. In most of these cases traders report they are selling food from their homes. However, it will be important to monitor food security at the household level to ensure that food (at reasonable prices) is reaching households especially in remote locations.

    •    Very preliminary data suggests a new risk to food security, or at least a potential delay in the rice harvests. Rainfall in September was much higher than it usually is at this time of year, but it did begin to decrease in October. This may negatively impact the rice harvest or at the very least delay the rice harvests.

    •    Food security is not just a function of food availability and price but also of income. The reduction in the number of traders suggests reductions in economic activity more generally which will depress income.

    More research on market activity is underway to measure the latest changes. In addition, other data collection efforts are attempting to capture the decline in economic activity more generally. We will report on the results of this work as soon as they are available.

    Researchers are presenting data to the government after it is gathered every month. 

    The Role of Information and Social Learning on Risky Sexual Behavior

    In 2009, an estimated 1.8 million people were infected with HIV in sub-Saharan Africa, with the vast majority of infections occurring through unprotected sexual intercourse before the age of 25. Women and girls experience a disproportionate share of this burden. This study evaluated a school-based HIV/AIDS education program, known as ISAS (Information, Teenage Sexuality and Health), on fertility, reproductive health, and high-risk sexual behavior of young girls in 8th grade.

    Policy Issue: 

    In 2009, an estimated 1.8 million people were infected with HIV in sub-Saharan Africa, with the vast majority of infections occurring through unprotected sexual intercourse before the age of 25. Women and girls experience a disproportionate share of this burden. In sub-Saharan Africa, young women aged 15-24 years are as much as eight times more likely than men to be HIV positive.1 This difference may largely be due to the unprotected sexual intercourse young girls have with older partners who are more likely to be infected. In order to minimize their infection risk for HIV, it is crucial for younger women to adopt safer sexual behaviors. A previous study found that young girls in rural Kenya were responsive to risk information and adapted their behavior in order to minimize their infection risk. This study aims to test the external validity of the previous finding, and disentangle between several factors of success to help setting up an optimal information tool against risky sexual behavior.

    Context of the Evaluation: 

    In 2007, 5.1 percent of the population of Cameroon was living with HIV. This proportion was even greater among young people between the ages of 15 and 24, with 6.2 percent living with HIV. Moreover, HIV prevalence was more than three times  higher among young girls than among boys. This may be largely attributed to girls becoming sexually active at a younger age. In 2006, 14 percent of girls between 15 and 19 years had their first sexual intercourse before the age of 14 in Cameroon.2 In an attempt to minimize new HIV infections among this vulnerable population, the Cameroon Ministry of Education and the Ministry of Health worked with researchers to design a generalizable school-based HIV/AIDS education program. The program targeted 13-year-old teenage girls since at this age, most teenage girls have not yet engaged in sexual activity but are likely to start soon.

     
    Details of the Intervention: 

    This study evaluated a school-based HIV/AIDS education program, known as ISAS (Information, Teenage Sexuality and Health), on fertility, reproductive health, and high-risk sexual behavior of young girls in 8th grade. The design of the program varied along two dimensions, the content and who delivered the message. The content was either phrased as a “classic government message,” which focuses on abstinence, fidelity, and condom use or a “relative risk message,” which uses this same curriculum, but adds information on infection rates by gender and age. The curriculum was taught by either permanent school staff or external consultants. Three hundred twenty  public schools were randomly divided into four groups.

    1. “Classic government message” delivered by permanent school staff
    2. “Classic government message” delivered by an external consultant
    3. “Relative risk message” delivered by an external consultant
    4.  No invention (comparison group)

    A baseline survey was administered in January of 2010. The information campaigns were then carried out between February and May. The follow up survey was completed between January and April of the following year.

     
    Results and Policy Lessons: 

    Results forthcoming.

     

    1 World Health Organization (WHO). Global AIDS Report 2010.

    2 World Health Organization (WHO). Epidemiological Fact Sheet on HIV and AIDS: Cameroon. September 2008.

    HIV/AIDS Prevention Through Relative Risk Information for Teenage Girls in Kenya

    Kenya's Ministry of Education has developed an AIDS curriculum for schools. However, this curriculum has not been effective in reducing the rates of infection and pregnancy. Information on the distribution of HIV infections by age and gender is not included in the official HIV curriculum for primary school. IPA evaluated the impact this information could have on teenager’s sexual decisions. Results found that girls exposed to the program were less likely to be pregnant in the next year. A follow-up survey is currently being conducted in order to measure longer-term impacts.

    Policy Issue: 

    The vast majority of HIV/AIDS cases occur in sub-Saharan Africa, where nearly 2 million people become infected with the virus 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, so policymakers must focus on other preventative measures. Ensuring the adoption of safer sexual behavior among youth remains critical to preventing the transmission of this disease.

    Context of the Evaluation:

    Kenya has the eleventh largest HIV infected population in the world -- over 6 percent of Kenyans are infected.1  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, the Kenya Ministry of Education, Science, and Technology integrated HIV/AIDS education into the primary school curriculum in 2001. However, by 2003, this curriculum had not been fully implemented, likely due to teacher inexperience and discomfort with talking about this sensitive material.

    Details of the Intervention:

    In Kenya, as in most African countries, 25-year-old men are far more likely to have HIV than 16-year-old adolescent boys. This means that sexual relationships with older partners (often called “Sugar Daddies”) are particularly dangerous for adolescent girls.

    Information on the distribution of HIV infections by age and gender is not included in the official HIV curriculum for primary school, however. To test the impact this information could have on teenager’s sexual decisions, ICS conducted a “Relative Risk Information Campaign” in 71 schools randomly selected among 328 primary schools involved in another HIV intervention evaluation. A trained project officer visited each of those 71 schools and, with the authorization of the teachers, spoke to Grade 8 students for a 40-minute period. Students were shown a 10-minute educational video on “sugar daddies”. The video screening was followed by an open discussion about cross-generational sex. During the discussion, the project officer shared the results of studies conducted in Kenya and Zambia and Zimbabwe on the role of cross-generational sex in the spread of HIV. In particular, the project officer wrote on the blackboard the detailed prevalence rates of HIV, disaggregated by gender and age group, in the nearby city of Kisumu, a place familiar to the students.

    Results and Policy Lessons:

    Impact on Unsafe Cross-Generational Sex: As a result of this intervention, the incidence of childbearing was reduced by 28 percent (from 5.4 percent of girls getting pregnant within a year, to 3.9 percent). This suggests that the intervention reduced the likelihood that girls engage in unsafe sex. Specifically, the intervention seems to have reduced unsafe cross-generational sex: the rate of childbearing with men five or more years older fell by 61 percent, with no offsetting increase in childbearing with adolescent partners. 

    Cost-Effectiveness: This targeted approach cost US$98 per pregnancy averted. Researchers came up with several possible estimates of cost per HIV infection averted based off of various estimates of the ratio of the risk of HIV infection to the risk of cross-generational pregnancy; these estimates ranged from just under US$400 to almost US$2,000. These rough cost-effectiveness estimates compare favorably with other HIV prevention programs, such as treating sexually transmitted infections, voluntary HIV testing, and male circumcision.

     

    1CIA World Factbook, “Kenya,” accessed June 6, 2012. https://www.cia.gov/library/publications/the-world-factbook/geos/ke.html.

    Selected Media Coverage:
    Pascaline Dupas

    Text Message Reminders for Malaria Treatment

    Only one drug—artemisinin—is fully effective in treating malaria in Sub-Saharan Africa, and is therefore central to the global fight against malaria; however, many patients do not complete the full course of malaria treatment. Non-adherence may increase the risk of drug resistance, greatly undermining efforts to combat the disease. This randomized evaluation in northern Ghana was a first attempt to evaluate the impact of text message reminders to patients on adherence to malaria treatment. Results indicated that text message reminders increased adherence to ACT treatment by five percentage points on average, relative to the comparison group. Further research is needed to develop the most effective text message content and frequency, and to shed light on why people fail to complete their medication.

    Policy Issue:

    In 2013, malaria killed more than 600,000 people across the globe – over half of them children under five [2]. Despite massive international efforts over the past decades to combat the disease, malaria remains a primary cause of death of young children worldwide. The great majority of global deaths from malaria—92 percent—occur in Sub-Saharan Africa [3]. The majority of malaria deaths in Africa are caused by the most virulent malarial parasite, P. falciparum. The parasitehas already developed widespread resistance to several classes of antimalarial drugs, leaving artemisinin-based combination therapies (ACTs), as the only fully effective treatment for malaria in the region.Patients must complete their full course of medication to prevent resistance, but many stop taking the drugs once they feel better. There is already evidence of P. falciparum resistance to artemisinin in Southeast Asia. Public health experts are deeply concerned resistance will also develop and spread in Africa.

    This study investigates the impact of text message reminders on ACT treatment completion. The Clinton Health Access Initiative, the main partner in this evaluation, is using results from this study, and related studies in Uganda (see hereand here), Kenya, and Zambia to inform global policy on malaria diagnosis and treatment.

    Context of the Evaluation:

    Malaria is a main cause of illness in Ghana, especially among young children. Two programs have increased patient access to ACTs to treat malaria. First, Ghana was a pilot country for the Global Fund’s Affordable Medicines Facility – malaria (AMFm), which aimed to expand access to ACTs by highly subsidizing their cost. Second, Ghana has been rolling out a National Health Insurance Scheme since 2004, which allows registered members to receive ACTs free of charge. This study took place in and around Tamale, the capital of Ghana’s Northern Region.

    Details of the Intervention:

    This randomized evaluation, carried out among 1,140 participants over a five-month period in 2011, evaluated the impact of text message reminders on whether patients finished their ACTs.

    IPA surveyors recruited participants at public and private hospitals, clinics, pharmacies, licensed chemical sellers, and other vendors. Vendors identified individuals purchasing malaria medicine, gave them a flyer with instructions to enroll in a mobile malaria information system, and directed them to surveyors. The surveyors administered an initial questionnaire to willing and eligible participants .

    Those who enrolled in the text messaging system were randomly assigned to one of the treatment groups or the comparison group. Participants randomly assigned to the one of the treatment groups received one reminder every 12 hours (for each of the six doses of ACT) over the course of 60 hours. Half received a short message, “'Please take your MALARIA drugs!” and the other half received the same message with an additional statement, “'Please take your MALARIA drugs! Even if you feel better, you must take all the tablets to kill all the malaria.” The 538 participants in the comparison group received no message during this period.

    IPA surveyors followed up with all patients in their homes between three and four days after talking with IPA at the vendor, when the course of the ACT treatment was supposed to be completed. Surveyors assessed adherence by gathering a detailed self-report. They supplemented this information with a full inventory of drugs in the household and by asking to see the leftover ACT pill packet. IPA also asked respondents about malarial symptoms, care-seeking patterns, awareness of malaria, and malaria medications.

    Results and Policy Lessons:

    Results indicated that simple text message reminders increased the odds of adherence to ACT treatment by five percentage points relative to the comparison group. Receiving a longer message did not have a significant impact relative to the comparison group.

    Of the 538 participants in the comparison group, 61.5 percent reported treatment completion. Of the 572 participants in the treatment group, 66.4 percent reported treatment completion. Of the participants that received the longer message, 64.1 percent completed their treatment, which was nota statistically significant impact.

    The impact of the text message reminders varied across different groups. For example, the short text message reminder more than doubled the odds of adherence among women but did not having a statistically significant impact on adherence among men. Among participants from private clinics, the text message reminder increased completion by 14 percentage points, whereas among patients from public hospitals, the increase was less than 2 percentage points in relation to the comparison group.

    In short, the results of this study suggest that a simple text message reminder can increase completion antimalarial treatment, which is important both for patients being fully cured as well as maintaining the efficacy of ACTs for everyone. Further research is needed to develop the most effective text message content and frequency.

    Read more about this study in the journal PLOS ONE, here.

    --

    The researchers would like to thank the Clinton Health Access Initiative, Jessica Cohen, Emmanuel Okyere Jr., Jessica Kiessel, Pace Phillips, Suvojit Chattopadhyay, Carolina Corral, Mollie Barnathan, Usamatu Salifu, Becky Antwi, and the entire IPA-Ghana team for their invaluable contributions to the project. They also wish to thank the host vendors and the patients for taking part in the study.

     

    The Impact of Health Insurance Education on Enrollment in Ghana’s National Health Insurance Scheme

    Government-subsidized health care is seen as a useful tool in tackling the health challenges in sub-Saharan Africa, but for it to work, people have to enroll in the program. Ghana offers universal health care, but only about a third of the population is enrolled. Some evidence suggested education about the insurance program would boost enrollment. However, a randomized evaluation in northern Ghana determined that education was not the barrier.

    Policy Issue
    Health outcomes in sub-Saharan Africa are on average very poor. While the region has 11 percent of the world’s population, it accounts for half of the deaths of children under five, has the highest maternal mortality rate and is disproportionately impacted by HIV/AIDS, tuberculosis, and malaria.[1]  Many people, especially in rural areas, lack access to basic health care services. To help tackle the problem, some governments are providing low-cost public insurance options. However, getting the population enrolled in such programs has been a challenge in some countries. One theory was that low enrollment was a result of lack of knowledge and understanding of health insurance, and that health insurance education would lead to higher enrollment rates.
     
    Context of the Evaluation
    Although Ghana's National Health Insurance Scheme has offered low-cost insurance since 2003, a large share of the population remains uncovered. As of 2010, the National Health Insurance Authority estimated that only 34 percent of the population was actively enrolled in health insurance. Coverage rates are especially low in rural areas, including Ghana's Northern Region.
     
    Preliminary qualitative research from international development organization Freedom From Hunger suggested that one reason for low enrollment was lack of knowledge and understanding of health insurance. Freedom From Hunger and IPA partnered to evaluate the impact of an education program developed by Freedom From Hunger on enrollment rates. Freedom From Hunger and IPA then partnered with a local microfinance institution Sinapi Aba Trust to administer the health insurance education program to Sinapi Aba Trust’s clients in both urban and rural areas in the Northern Region, Ghana, specifically in Bole, Salaga, Tamale, and Walewale.
     
    Details of the Intervention
    To understand if health insurance education leads to higher enrollment rates, researchers carried out a randomized evaluation with survey data from 1,500 Sinapi Aba Trust microfinance group clients. Credit officers with Sinapi Aba Trust administered the education program to microfinance groups after being trained by Freedom From Hunger.
     
    Three hundred microfinance groups were randomly selected from among Sinapi Aba Trust's client groups. The groups were stratified by branch, depending on whether the group was urban or rural, and whether initial insurance enrollment for the group was estimated to be high or low. Of those 300 groups, 120 were randomly assigned to the comparison group, while 45 were assigned to each of four treatment groups . All of the treatment groups received education covering planning for health expenses, the definition of health insurance and its benefits, and how to sign up for Ghana's National Health Insurance Scheme.
     
    The four treatment groups were as follows:
     
    Short session education: These credit groups received education through a series of six 30-minute sessions over 12 weeks.
     
    Short session education and reminder session: These credit groups were also given education through a series of six 30-minute sessions over 12 weeks, but with a session one year later that reviewed the material and reminded clients that to continue to have access to health insurance, they needed to enroll each year.
     
    Consolidated session education: These credit groups covered the same material as the “short session” groups but in one 2-hour session.
     
    Consolidated session education and reminder session:These credit groups covered the same material as the “short session” groups but in one 2-hour session, and with a reminder session one year later.
     
    A fifth, comparison group did not receive any education program.
     
    IPA conducted baseline, midline, and endline surveys with 1,500 respondents.  Within each client group, five individuals were randomly selected to be included in the study data. Sinapi Aba Trust credit officers administered post-education knowledge tests with a small subset of the sample. IPA also conducted a qualitative endline survey with a small a subset of the sample.
     
    Results and Policy Lessons
    Results indicated that individuals who received health insurance education were no more likely to enroll in health insurance than individuals in the control group.[2]
    While education may have had some impact on knowledge of insurance, the effect was short-lived. Notably, attitudes towards insurance were universally favorable, and knowledge of insurance generally high, regardless of treatment status. This suggests that knowledge was not a major barrier to health insurance enrollment in Ghana. Follow-up interviews suggest that the convenience of registration, clients following through on stated intent to enroll, and the timing of making the premium payments are more common challenges for enrollment. In environments where knowledge and enrollment are low, educational programs may, therefore, have more impact.
     
    Enrollment increased for all of the studied groups, including the comparison group that received no treatment, at a higher rate than the general population. It is possible that the repeated surveys, along with the treatment activities, might have served as “touch points” that prompted clients to take action to register or enroll in insurance.
     
    In sum, this study joins a growing body of evidence finding that in many contexts, the impact of education programs on health insurance enrollment is limited, especially where a program is established and generally well-known. This research suggests that efforts to promote enrollment should focus on other barriers to enrollment, such as convenience, timing of costs, and following through with intent to enroll. 
     
     
    [1]International Finance Corporation, “Health and Education in Africa.”
     
    [2]Schultz, Elizabeth, Metcalfe, Marcia, and Gray, Bobbi. “The Impact of Health Insurance Education on Enrollment of Microfinance Institution Clients in the Ghana National Health Insurance Scheme, Northern Ghana.” Microinsurance Innovation Facility, ILO. No. 33, May 2013. 
     

     

     
    Raymond Guiteras

    Online Sexual Education for Schools in Urban Colombia

    Can online sexual health education courses improve students’ sexual health knowledge, attitudes, and behavior? Do such courses also have positive effects on the peers of students who take the course? Researchers evaluated the impact of an online sexual health education course on the knowledge and sexual behavior of urban Colombian high school students. The education program led to significant impacts on knowledge and attitudes. No impacts were found on self-reported measures of behavior, but the program led to a reduction in incidence of sexually transmitted diseases among sexually active females. Moreover, results pointed to a significant increase for the treatment group in redemption of vouchers for condoms among students.

    Policy Issue:

    As young adults marry at older ages, they are more likely to have sex before marriage, increasing their risks of unwanted pregnancies and sexually transmitted infections (STIs). In low-income settings, adolescents face the added constraints of lower availability of information about safe sexual practices and restricted access to reproductive health services. Furthermore, sexual risk-taking in developing countries may have graver consequences because governments lack the resources and health systems to treat certain conditions.

    In recent years, the rise of information and communication technology programs has changed school-based sexual health education.Some research[1] suggests that for mainstream subjects such as math and reading, computer-based instruction may not work as well as conventional teacher instruction. We examined whether this is true for sexual health education, or if the reverse was true.

     
    Context of the Evaluation:

    In Colombia, only 55 percent of sexually active females aged 15-17 used a condom in their first sexual encounter.[2] This level of risk-taking is reflected in the fertility rate among adolescents in Colombia of 74 births per 1,000, compared to 41 per 1,000 in the United States, 14 in Canada, and five in the Netherlands.[3] By age 19, 20 percent of female adolescents in Colombia have been pregnant while 16 percent are already mothers. In order to tackle this challenge, legislation establishing sexual education as obligatory in Colombian public schools was passed in 1994, and national public policy was drafted by 2003.

    Profamilia is an internationally recognized non-profit provider of family planning and reproductive health services in Colombia, with over 33 clinics and 1,800 employees. A member of the International Planned Parenthood Federation since 1967, Profamilia is Colombia’s largest non-governmental organization focused on sexual health and reproductive health. Prompted by the deterioration of important adolescent sexual health indicators, such as teenage pregnancy rates, Profamilia’s education branch, Profamilia Educa, developed an online sexual education course for adolescents in public schools.

     
    Details of the Intervention:

    Researchers partnered with Profamilia to evaluate the impact of the online sexual health education course on the sexual health knowledge, behavior, and attitudes of Colombian high school students who took the course, as well as on their peers, who did not take the course. The study consisted of 138 ninth-grade classrooms from 69 public schools in 21 Colombian cities.

    The course had five separate modules covering the topics of sexual rights, pregnancy/family planning and the use of contraceptives, STIs/HIV and the use of condoms, objectives in life and the role of sexuality (empowerment), and prevention of sexual violence.Profamilia implemented the course in the school’s computer lab with teacher supervision. In addition, students had access to the course from any Internet-enabled computer using a password-protected account. Students were also assigned an anonymous remote tutor in the central Profamilia offices who would answer questions online related to the material individually and confidentially.

    Researchers collected data on the impact of the program both immediately after course completion and six months afterwards. Data was collected on students who took the course and students from comparison schools where the course was not offered. Also, to measure any effects on peers, researchers collected data on students who did not take the course, but went to schools where the course was offered. 

    To complement the self-reported data, and to come as close as possible to measuring the actual use of condoms in a credible manner,researchers offered students a voucher for six condoms six months after the end of the study. Profamilia recorded which students redeemed their voucher at the local health clinic.

     
    Results and Policy Lessons:

    The online sexual health education course led to significant impacts on knowledge and attitudes and a 52 percent increase in condom redemption. Although fewer STIs were reported for females who reported being sexually active in an initial survey, there was no impact on self-reported behavior on average. However, the program led to a large increase in redemption of vouchers for condoms, suggesting that the indeed the program did change behavior. Notably, the impacts of the course intensified when a larger fraction of a student’s friends was also treated.

    Knowledge: The course produced a 0.37 SD increase in overall knowledge one week after the intervention and a 0.38 SD increase in overall knowledge six months after the intervention. The lowest impact was found on the identification of situations of sexual violence - we found that treated beneficiaries were 0.11 SD more likely to correctly identify a situation of sexual violence.

    Attitudes: The course produced significant effects of 0.24 SD in terms of attitudes one week after the intervention and 0.17 SD six months after, which suggests some decay in attitude impacts over time.

    Sexual Behavior: The course did not change the average number of partners, frequency of sex, or rate of abstinence over the six months following the course. To go beyond self-reported measures, however, researchers found that 27 percent of treatment students redeemed the condom vouchers, compared to 18 percent of comparison students, a 52 percent increase. This result points to a significant increase in condom use.

    Social Networks: Researchers documented a strong social reinforcement effect: the impacts of the course intensified when a larger fraction of a student’s friends was also treated. In particular, when full sets of friends were treated researchers found significant reductions in sexual activity, frequency of sex, and number of partners. Throughout the analysis, researchers did not find evidence of effects on peers who did not take the course, i.e. “spillovers.”

    Cost-effectiveness: The marginal cost of the Profamilia course was approximately $14.60 per student. Compared to non-computer-based sexual health interventions in the United States, which range from $69 to more than $10,000 per student, the Profamilia course was extremely low cost.

    Policy Lesson: Web-based education is a plausible alternative in a context of tight budget constrains in public education given the widespread availability of the Internet in schools throughout the world and accelerated improvements in software quality. In societies where teachers may be unwilling or unable to provide sexual education, online courses may also prove a useful and cost-effective substitute for in-person instruction. Furthermore, the cost-benefit analysis suggests that because online sexual health education programs are extremely low cost, their measurable benefits in terms of STI reductions make up for the costs.


    [1] E.g. Barrera-Osorio, Felipe, and Leigh L. Linden. "The use and misuse of computers in education: evidence from a randomized experiment in Colombia." World Bank Policy Research Working Paper Series, Vol (2009).

    [2] DHS (2010) “Encuesta Nacional de Demografía y Salud - ENDS Colombia 2010”.

    [3] United Nations Statistics Division (2004) “Demographic Yearbook 2004”, New York: United Nations.

    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: http://www.unaids.org/en/regionscountries/countries/uganda/

    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 the world, within underserved populations with 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.

    Pay for Performance Health Care in Peru

    Systems of performance pay have become increasingly common in the public sector in the last decade in both developed and developing countries. Despite advances in these programs, there is great need to generate evidence on the effectiveness of performance pay systems and on how to optimize their design to suit the health sector. This impact evaluation aimed to assist Peru’s Ministry of Health in its development of a design for a pay for performance scheme.

    Policy Issue:

    Payment models that reward workers for meeting certain targets have long been used in the private sector to improve worker performance. Pay for performance schemes have become more common in the public sector over the past decade, and such schemes are now widely considered to be an essential tool for improving healthcare outcomes. The schemes involve providing rewards to physicians, hospitals, medical groups, or other healthcare providers for meeting certain performance measures for quality and efficiency. Despite advances in these programs, there is great need to generate evidence on the effectiveness of performance pay systems and on how to optimize their design to suit the health sector. This study contributes evidence on this topic.

    Note: This project is not a randomized control trial.

    Context of the Evaluation:

    In the last decade, in Peru, base wages in the health sector have not increased despite economic growth and a fiscal surplus. While the government has increased the salaries for some workers, its pay structure is outdated and, because of ad-hoc changes, inconsistent. Between September and October 2012, public sector doctors carried out a 33-day strike to protest low salaries, and the Ministry of Health considers reform of its pay structure necessary and urgent.

    As part of the reform of the health care sector, a performance pay scheme was legislated in order to improve access to and quality of health services. The Ministry of Health has expressed interest in receiving technical assistance in the design of performance indicators and improving the implementation and monitoring of the program, informed by international best practices. Before designing its program, the ministry is interested in testing different verification and payment schemes and assessing their effectiveness.

     
    Details of the Intervention:

    To inform the design of a potential randomized evaluation that would test modifications of on one or more operational aspects of the pay for performance program, University of California, Berkeley Professor Paul Gertler and IPA carried out three activities in partnership with Peru’s Ministry of Health.

    First, to extract relevant lessons for the Peruvian context, IPA carried out a literature review and collected international evidence on performance pay, including evidence from previous research by Gertler. IPA then held a workshop in which experts in the field shared their experience in implementing performance pay reforms in the public sector with Ministry of Health officials.

    Second, IPA used these findings to assess the pay for performance scheme included in the National Health Reform and provided recommendations. Because international evidence indicated that such schemes are most effective when employees are involved in the definition of performance indicators, IPA also performed approximately 40 interviews on possible indicators of performance from various levels of public health care providers and management and on the viability of systematizing that information.

    Third, IPA proposed three potential impact assessments of the pay for performance scheme, which would test operational modifications to the program. Before doing so, IPA worked with the ministry to identify a research agenda and define priority research questions and get feedback on various designs.

     
    Results and Policy Lessons:

    No results; this project was not a randomized control trial.

    Paul Gertler

    Negotiating a Better Future: The Impact of Teaching Negotiation Skills on Girls' Health and Educational Outcomes

    In Sub-Saharan Africa, young girls drop out of school at higher rates than boys. Parents often invest more in sons than in daughters, by allowing them more resources for education, such as school fees, and time away from house chores for studying. Adolescent girls are also more likely to contract HIV from older, more sexually active male partners, on whom they often depend for financial resources. Girls’ education and negotiation skills for women are therefore viewed as important tools for reducing school dropout rates, early pregnancies and the HIV rate among young women. This study, conducted in the capital of Zambia, assesses the impact of teaching girls negotiation skills on health and education outcomes.

    Policy Issue:

    When young girls drop out of school, they are often unable to develop the skills necessary to support themselves. They often rely on male partners for resources, and those partners often demand sex in return for financial support.  Such relationships are prevalent across sub-Saharan Africa, leaving young girls highly vulnerable to HIV infection and unwanted pregnancy, evidenced by the two-to-one ratio of HIV rates among young women versus their male counterparts. 1 The World Health Organization has identified negotiation skills for women and expanded efforts to keep girls in school as critical tools for reducing HIV rates among women in sub-Saharan Africa. 2 Designing school curriculum to provide girls with a stronger education and new skill sets has the potential to change gender dynamics and improve health outcomes for this vulnerable population.

    Context of the Evaluation:

    School data for Zambia shows a dramatic decline in female enrollment from primary to secondary school years.3  While this drop is normally attributed to the commencement of school fees in the eighth grade, a closer look reveals that school dropout rate increases prior to the fee increase. In grade five, the drop-out rate is three times higher for girls than boys. 4

    This project tests the impact of negotiation training in addition to the current school curricula on HIV/AIDS, health, and education outcomes among Zambian girls. Through a randomized controlled trial, this study analyzes whether negotiation skills that allow a girl to reshape her understanding of a conflict and her communications with others, can ultimately result in more favorable resource allocations.

    Details of the Intervention:

    This study isolates the impact of teaching information versus teaching negotiation by layering two interventions on top of a "social capital" program, including time with other girls in a safe space.

    About 2,400 grade eight girls from across 20 schools in Lusaka will be randomly assigned to participate in one of three two-week programs.  About 120 girls will be engaged per school, with roughly 40 girls in each program:

    • Social capital: girls meet after school to play games; receive  a snack notebooks, and pens

    • Information: girls meet after school to learn information on HIV and importance of schooling and to play games, also receive a snack, notebooks, and pens

    • Negotiation plus information: girls receive above program plus negotiation training

    The Negotiation Curriculum is structured by four principles: "Me," or identifying one’s own interests and options in conflict situations; "You," or identifying the other person’s interests, needs, and perspective; "Together," or identifying shared interests and small trades; and "Build," or developing win-win solutions.  The curriculum also accounts for some negotiations in which it is necessary to be patient, or "Take 5," and others in which the only outcome to keep the girl safe and healthy is to walk away and not negotiate.

    Outcome measures will measure both the size and source of impact, capturing transformations in the girl's capabilities, her interactions with others, and the outcomes of those interactions:

    • Survey data: Self-perception, outcomes of arguments and discussion, reported locus of control, intra-household allocations, and sexual risk exposure. Impact on the family measured through parent and sibling surveys to see if gains in participant well-being come at the expense of other family members.

    • Real outcomes (administrative data from schools): Rates of pregnancy, school attendance and advancement, and potentially STI/HIV rates

    • Behavioral measures: Take-up of an additional opportunity that requires child-parent negotiation, altered willingness to pay for schooling by parents, responses to negotiation scenario or partner game.

    Results and Policy Lessons:

    Results forthcoming.  If successful, this program curriculum could be scaled up countrywide in partnership with the Ministry of Education to increase schooling attainment and lower HIV infections at a relatively low cost.

    For more information about this project, click here.

    To watch a video about this project, click here.

    [1] (UNAIDS (2010) "UNAIDS report on the global AIDS epidemic" p.183)

    [2] WHO's Gender, Inequalities, and Health (2009): http://www.who.int/gender/hiv_aids/en/

    [3]UNICEF (2011) "State of the World's Children." p.107

    [4]Zambia DHS 2007, p. 21

    Nava Ashraf

    Contraceptive Adoption, Fertility, and the Family in Zambia

    Policy Issue

    As much as 75% of all pregnancies worldwide are unplanned or unwanted, accounting for nearly 300,000 new pregnancies every day.1  To the extent that rapid population growth can lead to low levels of human capital investment and continued poverty for future generations, the ability to control fertility can have broad social and economic consequences. Recent evidence suggests that access to contraceptives may improve economic outcomes and reduce poverty by allowing women to optimally time births, increasing women’s investment in education and participation in the labor market at childbearing ages. There are also direct consequences for individual well-being: significant reported need for contraceptives suggests that fertility outcomes outstrip fertility desires in many parts of the developing world.

    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.

    For more information about this project, click here and here.

    _____________________

    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)

    Nava Ashraf, Erica Field

    Empowerment and Livelihood for Adolescents in Sierra Leone

    Adolescent girls living in low-income settings may be trapped in a vicious cycle that prevents them from attaining employment and achieving better health outcomes and reproductive autonomy. Researchers will evaluate the impact of a program in Sierra Leone that aims to address this problem by bundling health education, vocational skills training, and micro-credit. They will evaluate the impact of these programs components, together and individually, on girls’ economic activity, engagement in sexual and risky behaviors, and future goals.

    Policy Issue:

    Adolescent girls in low income countries appear to be trapped in a vicious circle where low skills and poor labor market opportunities make girls turn to (often older) men for financial support; this increases the chances of childbearing that, in turn, further reduces the chances of acquiring useful skills and future labor force participation. In previous research in Uganda, researchers found that a combination of health education and vocational skills training can break the vicious circle. This study aims to assess where the causal chain starts, namely, whether it is the lack of health education, skills, or credit that keeps adolescent girls trapped in the vicious cycle of high fertility and low labor force participation.

     
    Context of the Evaluation:

    In Sierra Leone, teenage pregnancy and early childbearing are pervasive: of all pregnancies, 34 percent occur amongst teenage girls (SLDHS 2008) and 40 percent of maternal deaths occur as a result of teenage pregnancy (MICS 2010). In 2013, the Government of Sierra Leone launched a Strategy for the Reduction of Teenage Pregnancy, which aims to reduce the adolescent fertility rate by 4 percentage points by 2015. As part of this strategy, the government has partnered with UNICEF and BRAC to implement the Empowerment and Livelihood for Adolescents (ELA) program. BRAC is implementing the ELA program in six countries globally. In Africa, the program has already been implemented and evaluated in South Sudan, Tanzania, and Uganda.

     
    Details of the Intervention:

    Researchers designed a randomized evaluation, which is being implemented by IPA, to evaluate the impact of the ELA program and its various components on girls’ economic activity, engagement in sexual and risky behaviors, and aspirations. In addition, they will assess if the program affected girls who did not participate in the program but have social ties with those who had. 

    The program operates from adolescent development centers, or “clubs,” staffed by BRAC trained mentors, who are older adolescent girls from the same communities. Researchers will evaluate the following three program components, together and individually:

    • Health education ("life skills training") which is mostly delivered by trained mentors, covers the following topics: sexual and reproductive health, early pregnancy, menstruation and menstrual disorders, leadership among adolescents, gender, sexually transmitted infections, HIV/AIDS, family planning, gender-based violence, and adolescent responsibility within the family and community. Group learning is encouraged through participatory classroom trainings. In addition, the girls receive issue-based sexual and reproductive health training from the BRAC Health Program. Girls aged 13-24 can participate in the health education training.
    • Vocational (“livelihood”) training covers the skills required to engage in different income generating activities and financial literacy. Girls can choose to receive training in hairdressing, tailoring, animal husbandry, or agriculture. The training lasts about a month and is delivered by local service providers in Sierra Leone. The financial literacy module covers topics such as budgeting, financial services, financial negotiations, and accounting. Following successful completion of training, trainees receive input supplies to start their chosen business activity. To prevent school dropout, only girls aged 17-24 are eligible for training.
    •  Microcredit  Eligible girls who are engaged in a self-employment activity will be offered credit of up to US$100 to finance their business. The loan duration will be one year with an annual interest rate of 25 percent and weekly repayments. Girls aged 17-24 are eligible for credit.

    Participants will be randomly assigned to one of the following four groups, each consisting of 50 villages and 1,400 adolescent girls:

    (1)  Health education

    (2)  Health education, vocational training

    (3)  Health education, vocational training, microcredit

    (4)  Comparison group: No program

    Results from this replication study will allow for a cross-country comparison of the program’s effects and help to build the evidence on the program’s impact. In addition, by introducing different treatment groups this evaluation aims to separate the effects of the programs different components, which will provide important information to partners on how the program should be expanded. Moreover, information drawn from individuals about the relationships they have with others in their village, known as social networks data, will reveal how information and skills acquired by program participants spreads to non-participants.

    Results and Policy Lessons:

    Results forthcoming.  

    Read more about the ELA Sierra Leone program here

    Read about previous research on the program in Uganda here.

    The Demand for and Impact of Learning HIV Status in Malawi

    Policy Issue:

    At the end of 2009, over 33 million  people were living with HIV, with sub-Saharan Africa bearing an inordinate share of the global burden. Ten countries in southern Africa are home to 34 percent of the global population living with HIV, and experienced 31 percent of all new HIV infections in 2009.1 In order to curb the spread of the disease, many governments and international organizations have called for increased investments in HIV testing, under the assumption that individuals would act in their own self-interest to learn their HIV status and change their sexual behavior. Over the past few years, the number of voluntary counseling and testing (VCTs) facilities in sub-Saharan Africa has grown significantly and the cost of testing has been reduced dramatically, such that most testing is now free. However, utilization of these services remains low. Moreover, to date, little research has been done to investigate the actual impact of learning one’s HIV status on sexual behavior.

    Context of the Evaluation: 

    Eleven percent of adults in Malawi are infected with HIV/AIDS, giving the country the 9th highest prevalence in the world.1 Although the HIV prevalence rate in the sample area was considerably lower than the national rate, at 6.3 percent, it was comparable to, or greater than, the prevalence rate in much of sub-Saharan Africa. For comparison, in 2009, the HIV prevalence rate in Kenya and Sierra Leone was 6.3 percent and 1.6 percent, respectively.1

    Although the national HIV prevalence rate has decreased over the past decade in Malawi, hundreds of people are still infected each day. In 2009, there were 73,000 new HIV infections in Malawi.[1] In the face of this epidemic, policymakers and NGOs face an urgent need to develop effective prevention programs, including voluntary counseling and testing (VCT) interventions. Although surveys in several African countries report that over two-thirds of individuals who did not know their HIV status would like to get tested, the proportion of adults who actually utilize the available testing services is much lower, below 15 percent in some areas. Even when individuals choose to have an HIV test, many do not return for their results. In clinics across Africa, only about 65 percent of individuals returned to learn their result after being tested.

     
    Details of the Intervention:

    Researchers evaluated the Malawi Diffusion and Ideational Change Project (MDICP), a collaborative project between the University of Pennsylvania and the Malawi College of Medicine. MDICP sought to explore the determinants of the demand for, and the impact of, learning one’s HIV status. The evaluation was undertaken in approximately 120 villages in three districts of Malawi. Approximately 25 percent of households in each village were randomly selected. From these households, a total of 1500 ever-married women between the ages of 15 and 49 and their husbands were interviewed in 1998, 2001, 2004, and 2006. In 2004, a random sample of approximately 800 young adults (both married and unmarried) between the ages of 15 and 24 was added to the sample. 

    In 2004 and 2006, respondents were offered free door-to-door testing for HIV by trained VCT counselors who came from areas of Malawi outside the respondent’s district but who were native speakers of the local language. After consenting to be tested, respondents were given pre-test counseling about HIV prevention strategies and a detailed explanation of testing techniques. The VCT program differed slightly between years. 

    In 2004, samples were taken through oral swabs and sent to a laboratory to be tested. Respondents were given randomly assigned vouchers for between zero and three dollars, redeemable upon obtaining their results two to four months later at a nearby VCT center. The location of the VCT centers was also randomized as to evaluate the impact of distance, and thus travel time, for participants on VCT attendance. The average distance to a center was 2 km, with over 95 percent of those tested living within 5 km. At the center, regardless of their test result, each respondent also received approximately 30 minutes of counseling on safe sexual practices, including abstinence and condom use. About two months after the tests became available, respondents were re-interviewed in their homes and given the opportunity to purchase condoms at half the subsidized retail price: five cents for a package of three condoms or two cents for a single condom. 

    In 2006, the VCT program was adjusted slightly in an effort to improve take up. First, before testing began, village meetings were held to explain the purpose of the home visit and allow community members to see a first-hand demonstration of the testing technology. In 2006, respondents’ HIV status was measured using a rapid blood test, which provided much quicker results than oral swabs. After 15 minutes, with the help of VCT counselors, respondents were able to read the test results themselves – one visible red line indicated a negative HIV test result, while two lines indicated a positive result. Subsequently, the respondent accompanied the counselor to the nearest pit-latrine to dispose of all test-related devices.

     
    Results and Policy Lessons:

    2004 Program

    Impact of Monetary Incentives and Distance: The demand for HIV test results among those who received no monetary incentive was fairly low, with only 35 percent  of those tested collecting their results. However, monetary incentives were highly effective in increasing result-seeking behavior. On average, respondents who received any cash-value voucher were twice as likely to go to the VCT center to obtain their HIV test results as those who received no cash incentive. Although the average incentive was worth about a day’s wage, even the smallest amount, about one-tenth of a day’s wage, resulted in large attendance gains. Distance also had a significant impact on the likelihood of obtaining HIV test results. Those living more than 1.5km from the VCT center were 3.8 percentage points, or 6 percent, less likely to collect their results than those living within 1.5km.

    Peer Effects: The presence of social networks had a significant impact on the likelihood of learning one’s HIV status. Specifically, a 10 percentage point increase of the percentage of neighbors (approximately 2.4 individuals) learning their HIV test results increased the probability of learning HIV results by 1.1 percentage points. This effect was greatest for neighbors living within close geographic proximity and for those living further away from the HIV results centers. In contrast, religious networks had no significant impact on learning HIV results.

    Impact on Sexual Behavior: Learning HIV status did not significantly affect condom purchasing behavior for most people. Overall, 24 percent purchased at least one condom; among those who purchased any, the average number purchased was 3.7. Among sexually active individuals, on the other hand, receiving an HIV positive diagnosis significantly increased the likelihood of purchasing condoms. However, the overall magnitude of the effect was small. On average, sexually active individuals who learned they were HIV-positive purchased only two more condoms than HIV-positive individuals who did not learn their results.

    Impact on Subjective Beliefs and Economic Behavior: Although learning HIV results had a short-term effect on subjective beliefs about the likelihood of HIV infection, it had no long-term impact. Accordingly, obtaining either HIV-positive or negative results had few significant effects on longer-term economic behavior. Two years after receiving their results, there were few significant differences between HIV-positive and HIV-negative individuals in propensity to save, amount worked in the past 6 months, income, or expenditures.

    2006 Program

    In 2006, 92 percent of respondents agreed to be tested, of whom 98 percent received their results. This compares to the VCT program in 2004, where 91 percent of respondents agreed to be tested, but only 69 percent of all respondents ever received their results, and only 34 percent of respondents receiving no monetary incentives collected their results. Semi-structured interviews with a subset of the sample and observational data suggest that the large proportion of respondents who consented to be tested in both 2004 and 2006 was likely due to respondents’ strong preference for door-to-door testing, because it was convenient and confidential. Door-to-door testing removed the obstacle of travel, which is time-consuming and costly, and provided much more privacy than a hospital. The VCT counselors also came from areas outside of the sample villages and were, therefore, not familiar with the respondents prior to testing.

    Both of these factors – convenience and confidentiality – can also help to explain the significant increase in the proportion of respondents who received with results in 2006. In addition, respondents reported that they highly preferred the rapid blood test. The rapid test ensured that their results had not been tampered with and/or confused with someone else's; it also eliminated the anxiety of the waiting process. Respondents also favored the rapid blood test because it convinced them of the accuracy of their test result. The red line(s) on the test kits allowed respondents to see their test result with their own eyes, rather than having to trust that the counselor was reporting the correct results. Furthermore, the method of disposing the test kits in front of the respondent was also seen as an advantage, as it ensured that the evidence of the test itself was removed permanently.

    1  UNAIDS (2010) “UNAIDS Report on the Global AIDS Epidemic.”

    Related Papers Citations: 

    Angotti, Nicole, Agatha Bula, Lauren Gaydosh, and E. Yeatman. 2009. "Increasing the Acceptability of HIV Counseling and Testing with Three C's: Convenience, Confidentiality, and Credibility." Social Science & Medicine 68(12): 2263-70.

    Godlonton, Susan and Rebecca Thornton. 2012. “Peer Effects in Learning HIV Results.”Journal of Development Economics 97: 118-129.

    Godlonton, Susan, and Rebecca Thornton. "Marital Investment under Uncertainty: Couples HIV Testing and Marital Stability." Working Paper, April 2013.

    Godlonton, Susan, and Rebecca L. Thornton. 2013. "Learning from Others' HIV Testing: Updating Beliefs and Responding to Risk." American Economic Review Papers and Proceedings 103(3): 439-44.

    Thornton, Rebecca L. 2008. "The Demand for, and Impact of, Learning HIV Status." American Economic Review 98(5): 1829-63.

    Thornton, Rebecca. 2012. “HIV Testing, Subjective Beliefs and Economic Behavior.” Journal of Development Economics 99(2012): 300-13.

     

    Rebecca Thornton

    Evaluating the African Health Market for Equity (AHME) Initiative in Ghana and Kenya

    Sub-Saharan Africa accounts for 24 percent of the global burden of disease. While private clinics are the first source of care for many Africans, the quality of care offered in private facilities is inconsistent and often weak, and the private healthcare sector faces a wide host of challenges. In this study, IPA-affiliated researchers from UC Berkeley and UCSF will evaluate the impact of a multi-pronged private healthcare initiative on healthcare utilization, quality of care, clinic financial outcomes, and child health outcomes in Kenya.

    Policy Issue:

    Sub-Saharan Africa accounts for 24 percent of the global burden of disease,[1] yet it only has 11 percent of the world's population. The health care systems of the countries in the regions are facing numerous challenges at once, including lack of training and organization, insufficient standards and quality monitoring, and high out-of-pocket expenditures.  While many efforts to address problems in the health care sector have focused on government clinics and hospitals, private providers are in fact the first source of care for many Africans. Though millions of people rely on private clinics, regulation and enforcement of quality care in private facilities is generally weak, and the private healthcare sector is not structured to ensure either quality or affordability.[2]These issues have impelled governments and NGOs to turn their attention to improving care in private facilities. Thus far, many programs have aimed to solve individual constraints to providing high-quality health care, but few have intervened on multiple fronts simultaneously. A multi-faceted approach has not been tested. This research will fill this gap by testing an initiative that addresses multiple health challenges in the region at once.

     
    Context of the Evaluation:

    Ghana, Kenya and Nigeria, the countries participating in the African Health Market for Equity (AHME) initiative, all have large populations, a high disease burden, high out-of-pocket payments for healthcare, and they are all working to expand the reach of their health insurance programs. The initiative was designed and is being implemented by Marie Stopes International, Population Services International, PharmAccess Foundation, Grameen Foundation, the International Finance Corporation, and Society for Family Health.

    AHME is a multi-faceted initiative that aims to improve both the supply and demand for private healthcare among the poor. Supply-side interventions aim to ensure high quality of care, while demand-side interventions aim to reduce barriers to accessing high-quality care. Evidence suggests that grouping private providers under a franchised brand with a social goal could improve both access to and the quality of some clinical medical services. Such “social franchising” entails creating a valued brand for goods or services, with a social goal, and extending the reach of that brand by leasing the right to use it. A social franchise model serves as the basis for the AHME initiative. In addition, the initiative includes training in basic clinical management and strategic planning for quality improvement and access to credit to implement improvement plans. AHME will also facilitate government registration for clinics. Finally, clinic personnel will use information and communication technology (ICT) to improve operational efficiency.

     
    Details of the Intervention:

    Researchers Paul Gertler (UC Berkeley) and Dominic Montagu (UCSF) will use a randomized evaluation to evaluate both the effectiveness and cost-effectiveness of the AHME program at improving quality of care, service utilization, access to high-quality care, and health outcomes. While the initiative is taking place in Ghana, Kenya and Nigeria, the initiative is being evaluated only in Ghana and Kenya, and the randomized evaluation is occurring in Kenya only.

    In Kenya, the researchers will randomly assign private clinics that meet criteria for selection into the AHME program to either a treatment or comparison group. Clinics in the treatment group will be invited to participate in AHME immediately, while clinics in the comparison group will be recruited into AHME after the evaluation is complete.

    Clinics participating in AHME will receive five interventions:

    1.     Social franchising: Private providers will be trained and certified to deliver standardized care under a franchised brand. The brand aims to signal to the client that the clinic offers high-quality services. Local and national marketing for the brand aim to build demand for the franchised services.

    2.     SafeCare: The program provides participating clinics with a standardized assessment of facility quality, support in developing quality improvement plans, and incentives for clinics to improve quality of care. 

    3.     Medical Credit Fund: The fund provides strategic planning support tied to performance-based financing to eligible SafeCare-participating clinics.

    4.     Demand-side financing: AHME will facilitate registration with Kenya’s National Health Insurance Fund for SafeCare-participating clinics that meet a minimum standard of quality.

    5.     Information and communications technology (ICT): Mobile phones and other technology will be utilized to enable clinic personnel to, among other things, collect data and directly reach clients.

    Data will be collected over a four-year period at both the clinic and household level to measure healthcare utilization, quality of care, clinic financial outcomes, and child health outcomes.

    The impact evaluation in Kenya will be a collaborative effort between Innovations for Poverty Action and researchers from the University of California, Berkeley, who will lead the overall evaluation, and the University of California, San Francisco, who will lead the accompanying qualitative evaluation.

    The qualitative evaluation will take place in Ghana and Kenya over the same four-year period to complement the quantitative findings. The qualitative evaluation will explore provider and client attitudes towards quality of health and options for care and will describe the AHME operation processes and their effects on the overall markets and institutional environments in which they function. Members of the research team will conduct in-depth interviews with providers participating in AHME and their clients and carry out focus group discussions in communities surrounding AHME facilities. The researchers will also conduct key informant interviews with AHME partner organizations and other key project stakeholders.

     
    Results and Policy Lessons:

    Results forthcoming.

     


    [1]UNEP. “Global Shortage of Health Workers.” http://www.unep.org/training/programmes/Instructor%20Version/Part_2/Activities/Dimensions_of_Human_Well-Being/Health/Supplemental/Global_Shortage_of_Health_Workers.pdf

    [2]Prata, Ndola, Dominic Montagu, and Emma Jefferys. "Private sector, human resources and health franchising in Africa." Bulletin of the World Health Organization 83, no. 4 (2005): 274-279.

    Paul Gertler

    Demand for Sanitation in Kenyan Urban Slums

    Sanitation is essential to health and welfare, but as many as 2.5 billion people in the developing world have no access to improved sanitation. In slums near Nairobi, Kenya, IPA-affiliated researchers from UC Berkeley and the University of Maryland are testing how subsidizing the cost of connecting to the sewer system and providing information about the health benefits of improved sanitation affects the number of landlords who connect to the sewer system.

    Policy Issue:

    Safe water and sanitation are essential to health and welfare, but as many as 2.5 billion people in the developing world have no access to improved sanitation. In urban areas, the lack of adequate sanitation disproportionately affects poor residents in informal settlements. Improved water supply and sanitation could provide a wide range of benefits, including longer life spans, reduced disease prevalence, and lower health costs.

    Many governments recognize these potential gains in public health and have begun investing in expensive sewer systems. However, the cost-effectiveness of these investments depends on the number of households that connect to the new sanitation infrastructure. There are large fixed costs to connection: utilities often charge a connection fee and households must purchase toilets and pipes. Poor households may not have cash on hand to cover these costs, and they may be unwilling to pay if they do not understand the relationship between sanitation and health. This study explores the reasons households may not invest in sanitation by evaluating how changing the price and providing information about the benefits of improved sanitation affect the demand for sewer connections.

     
    Context of the Evaluation:

    The Government of Kenya will spend US$427 million on water and sanitation infrastructure over the next two years as part of the World Bank-funded Water and Sanitation Service Improvement Project. The goal of this large project is to improve access to clean water and improved sanitation throughout the country.

    Koyole Soweto, an informal settlement in Nairobi, has a population of approximately 85,000 people. Slums like Koyole Soweto are very crowded: a single compound often houses multiple families in 6-10 dwellings. About 70 percent of landlords live in one of the dwellings in the compound, and they lease the other dwellings to different households. A single connection to the sewer system serves the entire compound, but it is the landlord who decides whether to invest in a sewer connection.

     
    Details of the Intervention:

    IPA-affiliated researchers from UC Berkeley and the University of Maryland are partnering with the Athi Water Services Board, which is responsible for introducing both piped water and sewerage services in Koyole Soweto. Installing a water connection is relatively cheap, so program implementers expect near-universal take-up. However, the cost of a sewer connection is much higher (US$250) and is a lower priority for most households, so researchers are evaluating how subsidizing the price of a sewer connection and providing information about the health benefits of proper sanitation affect the number of landlords who choose to connect to the sewer system. In addition, they are measuring if connecting to the sewer system ultimately affects housing rental prices.

    Approximately 2,200 compounds in Koyole Soweto will be randomly assigned to receive different subsidy amounts, sometimes paired with an information campaign. This will result in six groups of 366 compounds, receiving either:

    • A small subsidy for a sewer connection
    • A small subsidy, plus an information campaign emphasizing the relationship between sanitation and health
    • A medium-sized subsidy for a sewer connection
    • A medium-sized subsidy, plus the information campaign
    • A large subsidy for a sewer connectionA large subsidy, plus the information campaign

    Landlords who live in the compound may think about the decision to connect to the sewer system differently than those who live elsewhere, as resident landlords will enjoy the convenience and health benefits of new sanitation facilities. However, absentee landlords may be able to raise their tenants’ rent after installing a sewer connection. In order to determine how behavior varies between these two types of landlords, researchers will make sure each group has similar numbers of resident and absentee landlords.

    Results and Policy Lessons:

    Project ongoing, results forthcoming.

    Free Distribution or Cost-Sharing: Evidence from a Malaria Prevention Experiment in Kenya

    Bednets treated with insecticide are a proven way to deter mosquitoes and prevent deadly malaria. But how can we get more people to use these potentially lifesaving items? Some argue that those who pay for a good will value it more and use it more compared to those who receive it for free. We found no evidence that women receiving free nets were less likely to use them than those who paid a price for them. Charging for nets does however considerably reduce access, dropping by 75 percent when the price increases from zero to $0.75. Overall, our results suggest that free distribution is both more effective and more cost-effective than charging (even a subsidized price) for nets.

    Policy Issue:

    Malaria is one of the world’s foremost public health concerns, causing as many as 1 million deaths each year, the majority of which occur in sub-Saharan Africa.1 Malaria is often associated with poverty—the poor are most affected, likely because they have reduced access to medical services and information, and the lowest ability to avoid working in malaria epidemic areas. The disease can also perpetuate poverty—taking a high toll on households and healthcare systems and reducing GDP by an estimated full percentage point each year in malaria-endemic countries.2 The spread of malaria can be greatly reduced with the use of preventive strategies such as insecticide-treated bed nets (ITNs).

    There is a general consensus among academics and policymakers that provision of public health goods with positive externalities should be publicly financed. But this consensus coexists with a long-running debate on what proportion of the cost the beneficiaries of these public health programs should be bear. Standard economic analysis implies that goods (such as ITNs) that have a positive benefit (such as reduced malaria transmission) to the whole community when they are used by individuals should be provided at zero cost to the user. However, some argue that charging for health tools may increase their usage intensity, by screening out those who do not value the good, and inducing people to rationalize their purchase by using the good.

    Although cost sharing may lead to higher usage intensity than free distribution, it may also reduce program coverage by dampening demand. And if people who cannot afford the price are more likely to be sick, then, by selecting these people out, charging could significantly reduce the health benefits of the partial subsidy.

    Context of the Evaluation:

    In Kenya, malaria is responsible for one out of every four child deaths.3 It impacts economic growth and productivity, and almost 170 million working days are lost annually due to the disease.4 ITNs are used to prevent malaria infection and have been proven highly effective in reducing maternal anemia and infant mortality, both directly for users and indirectly for non-users with a large enough share of net users in their vicinity. ITNs have been shown to reduce overall child mortality by an average 20% in regions of Africa where malaria is endemic. Despite their proven efficacy, in Kenya only 5% children and 3% of pregnant women sleep under an ITN. Priced at US$5-7 per net, they are not affordable to most families, and so governments and NGOs often distribute ITNs at heavily subsidized prices.

    Details of the Intervention: 

    This program targeted ITN distribution to pregnant women who visited clinics for prenatal care.

    First stage: Sixteen health clinics were randomly selected to receive ITNs at a subsidized rate, with the discount varying between clinics from 90-100% of market price, and four comparison clinics were provided no ITN distribution program.

    Second stage: Within a given clinic, a further discount is randomly offered to women who have already chosen to buy the net. This second stage is intended to allow separate estimation of the selection and sunk cost effects of price on usage discussed above.

    Administrative records at the clinics were collected; data on the number of women enrolling for and receiving prenatal care services and the percentage of prenatal clients acquiring an ITN was recorded. Individual-level data was acquired through interviews with pregnant women. Women were asked basic background questions, whether they purchased a net, and their hemoglobin level was recorded.

    Results and Policy Lessons:

    Impact on ITN Usage Intensity: No evidence was found to suggest that cost-sharing increases ITN usage: women who paid positive subsidized prices were no more likely to use nets than those who received ITNs for free. Additionally, there is no evidence that cost-sharing puts ITNs in the hands of women who need the net most: those who pay higher prices appear no sicker than the prenatal clients in the comparison group in terms of measured anemia (an important indicator of malaria).

    Impact on ITN Demand: Cost-sharing does considerably dampen demand. ITN uptake drops by 60 percentage points when the price increases from zero to $0.60, a price still $0.15 below the price at which ITNs are currently sold to pregnant women in Kenya. These results imply that demand for ITNs is 75% lower at the cost-sharing price prevailing in Kenya at the time of the study ($0.75) than it is under a free distribution scheme.Overall, given the large benefit to the community associated with widespread usage of insecticide-treated nets, results suggest that free distribution of ITNs is both more efficient and more cost-effective than cost-sharing.

    1 WHO, "10 Facts on Malaria," http://www.who.int/features/factfiles/malaria/en/index.html.
    2 African Medical & Research Foundation, (AMRF), “Fact sheet – Malaria,”http://usa.amref.org/index.asp?PageID=87.
    3 The World Bank, “News & Broadcast: World Bank Intensifies Anti-Malaria Efforts in Africa”,http://go.worldbank.org/IWWIICOOC0.
    4 The World Bank, “Booster Program for Malaria Control in Africa – Kenya,”http://go.worldbank.org/EGMG4G6DX0.

     

    Household Water Connections in Morocco

    Many people in the developing world lack access to clean water.  Can providing clean water make kids healthier? Will children attend school more often? Will adults be able to work more regularly? We worked with the Government of Morocco to evaluate the impact of offering piped water connections at a subsidized price, and on credit. It turned out that there were no major health or educational benefits as most households already had access to free public taps, but people were willing to pay for a private tap at home, and the time saved walking to the tap made for more free time and higher self-reported happiness.

    Policy Issue: 

    Households in developing countries spend considerable amount of time fetching water. The time-burden of water collection does not typically spare anyone in the household, but in many countries it is borne primarily by women and girls. Most interventions to connect poor households to the drinking water network are primarily concerned with improving physical health. Yet, over and beyond its direct effect on physical health, improved water access could have important effects on the household well-being. By reducing the time burden of water collection, improved water access not only frees up time that could be spent on additional leisure or production (paid labor or schooling), but also removes an important source of stress and tension. But it might also be welfare-reducing as women face restricted mobility outside of excursions to collect water. An in-home water connection could cut off an important opportunity to socialize.

    Context of the Evaluation: 

    In urban Morocco, the setting of this study, households that rely on public taps spend more than seven hours a week collecting water, despite a relatively high density of water taps. In our sample, 65% of households without a water connection report that water is a major source of concern: 15% have had a water-related conflict within the family and 12% with their neighbors. Thus, both within the family and between families, water seems to be the primary source of stress and tension.

    Details of the Intervention: 

    J-PAL worked in collaboration with Amendis, the local affiliate of an international private utility company, which operates the electrical and wastewater collection networks as well as the drinking water distribution in Tangiers, Morocco. In 2007, Amendis launched a social program to increase access to piped water and sanitation. As of the end of 2007, approximately 845 low-income households living in “on-the-grid neighborhoods” of Tangiers (i.e. in principle easily connectable) did not have a household water connection because they could not afford the connection fee. These households had free access to public taps in their neighborhood, however, and they also all had sanitation facilities at home.

    The program provided a subsidized interest-free loan to install a water connection. The loan was to be repaid in regular installments with the water bill over three to seven years. The subsidy did not cover the cost of installing the connection or the cost of water consumed. To pilot-test the program, a door-to-door awareness campaign was conducted in early 2008 among 434 households, randomly chosen from the 845 that needed a connection. Those households received information about the credit offer as well as help with the administrative procedures needed to apply for the credit. The remaining households (the comparison group) were eligible to apply for a connection on credit if they wanted to, but they received neither individualized information nor procedural assistance until 2009.

    Results and Policy Lessons: 

    Since the participating households already had access to the water grid through free public taps, no improvements in the quality of water consumed by households have been found. Despite significant improvement in water quantity, no change in the incidence of waterborne illnesses was found. Nevertheless, households are willing to pay a substantial amount of money to have a private tap at home. Getting connected generates important time gains, but does not lead to increases in labor market participation, income, or schooling attainment. The spared time seems to be used for leisure and social activities.  Because water is often a source of tension between households, home connections appear to improve social integration. Overall, despite the financial cost, households’ self-reported happiness improves substantially when they are connected to the water system at home.

    Chlorine Dispensers for Safe Water in Kenya

    Policy Issue:
    Two million children die of diarrheal disease each year and contaminated water is often to blame. Treating water with chlorine could substantially reduce this toll. The most common approach to chlorination in areas without piped water infrastructure is to offer small bottles of chlorine for sale to consumers.However, chlorine use has been slow to catch on in this system. In this Kenyan study area, for example, less than 10% of households regularly use chlorine at a monthly cost of approximately US$0.30, despite several years of vigorous social marketing that has raised awareness about the product
     
    Details of the Intervention:
    Researchers examined free provision of dilute chlorine via a point-of-collection system, which includes a container to dispense the product placed at the water source, a local promoter to encourage the product’s use, and free provision of a supply of chlorine solution packed in bulk. This bulk supply dramatically reduces delivery costs relative to the retail approach, which requires packaging chlorine in small bottles, and relative to door-to- door distribution, which in addition significantly raises marketing costs. Hence, bulk distribution to water sources makes free provision more realistic. Additionally, this delivery method makes chlorine use very convenient. Users can treat drinking water when they collect it. The required agitation and wait time for chlorine-treated water are at least partially accomplished automatically during the walk home from the source. The source-based dilute chlorine disinfection approach to water treatment makes this act salient and public, in addition to making it cheaper and more convenient. The dispenser provides a daily visual reminder to households to treat their water at the moment when it is most salient—as water is collected—and maximizes the potential for learning, norm formation, and social network effects by making the dispenser public. Potential users can see others who use the dispenser, and they have the opportunity to ask questions; they will also know that others will see whether they use the dispenser
     
    Results and Policy Implications:
    Take-up of chlorine provided through dispensers dramatically exceeded take-up of chlorine for treating water for in-home use. When communities were randomly assigned to receive a promoter and a community dispenser, take-up was approximately 40% in the short run (three weeks) but climbed to more than 60% by the medium term (three to six months), representing 37- and 53-percentage point gains, respectively, compared to the communities that did not receive them.
     
    In contrast to the take-up levels achieved with the dispensers, clinic-based coupon redemption started higher and dropped over time. More than 40% of households that were given coupons redeemed them 8 months into the program, but this figure fell to 20% by 12 months. This finding suggests that the success of the dispenser may be due not only to the zero price but also to the reduction in the psychic cost of remembering to treat water that is achieved by source-based treatment as well as other attributes, like the visual reminders. Although take-up rates are slightly lower than those achieved in some trials, the dispenser system relies far less on outside personal contact (e.g., from repeated household visits from enumerators) than do those approaches; hence, costs are significantly lower. The chlorine dispenser is extremely cost-effective, with a comparative study finding dispensers the most effective from a range of low cost approaches to reducing diarrhea. 
     
    The success of the chlorine dispensers at the proof-of-concept stage described here led to a concerted effort to scale the intervention up as a sustainable program. As of April 2014 over 1.8 million people were being served by chlorine dispensers, with plans to reach four million by the end of 2014.
     
    The program has transitioned to Evidence Action, a new organization started with the support of IPA to scale evidence-based initiatives. More information can be found on their website here.
     

    Recruiting and Motivating Community Health Workers in Zambia

    Employing community health workers may help governments address the shortage of healthcare providers in Sub-Saharan Africa. However, it is unclear how offering incentives such as career advancement opportunities might affect who self-selects into community health worker jobs. Researchers partnered with the Government of Zambia to test the effect of two incentive strategies on applicants’ characteristics and job performance. They found that making career incentives rather than social incentives salient attracted workers who were more qualified and performed better on the job and had similar levels of pro-social preferences.
     
    Policy Issue:
    The provision of public services—governance, health care, education—depends critically on the effort of the workers tasked with providing them. Effort can be increased in two ways: through incentives that directly reward it and through the selection of workers who are predisposed towards exerting it—that is, who have high intrinsic motivation. These two mechanisms are linked because incentives may affect not only effort on the job, but also who self-selects into a job. The effect of incentives on self-selection into public service jobs remains largely unexamined.
     
    Context of the Evaluation:
    In 2010, the Government of Zambia launched a national effort to create a new civil service position: the Community Health Assistant (CHA). The government aims to train 5,000 new CHAs by 2017—a massive investment in a country with only 6,000 nurses. CHAs undergo a year of formal training, and then return to their rural home communities to work. The majority of their work consists of household visits, but they also spend one day a week in the community health post and organize community health-education meetings. They are the first line of healthcare for Zambians living in the most remote regions of the country.
     
    Description of Intervention:
    Researchers tested how private incentives, in the form of opportunities for career advancement, affect the skills and motivation of applicants for a new health worker position and how, in turn, this self-selection affects job performance.In the first year of the program, the Ministry of Health aimed to recruit 330 CHAs, two from each of 165 rural health posts in 48 districts of Zambia. In a randomly selected half of the districts, recruitment posters emphasized the “social” benefits of becoming a CHA, such as serving and being a leader in one’s community. In the other half, recruitment materials emphasized the “career” benefits of becoming a CHA, such as opportunities for promotion and further professional development.
     
    Other than the differing emphasis on social or career benefits, the recruitment materials and selection processes were identical. They specified that applicants needed to be Zambian nationals, ages 18-45, with a high school diploma and passing grades for at least two subjects on their secondary school graduation exams. The government received over 2,400 applications and interviewed 1,585 eligible candidates. Three hundred and fourteen attended a year-long training, and 307 graduated and began work as CHAs. Once deployed, actual benefits were identical between the two treatment groups—that is, all CHAs had the same job description (and thus the same social benefits) and the same private incentives, including the possibility of promotion after two years of service. As a result, any difference in performance was due to the selection effect of the incentives.
     
    Results and Policy Lessons:
    Career incentives attracted CHAs that were more qualified and had the same level of pro-social preferences as CHAs recruited by making social incentives salient. These CHAs consequently performed better on the job. By highlighting opportunities for career advancement, governments may be able to recruit better skilled and better motivated applicants to work in public service.
     
    Pro-social and career preferences: Applicants recruited under both approaches displayed similar levels of pro-social preferences: about 84 percent of both groups perceived their self-interest as overlapping with their community’s interests, and a little over half planned to stay in the same community for the next 5-10 years. However, applicants recruited by making career incentives salientwere more ambitious regarding career advancement: a larger portion aspired to hold a higher-ranking government position in the next 5-10 years.
     
    Ability: Applicants recruited by making career incentives salient were 6 percentage points more likely to qualify for university admission (compared with 71 percent of applicants recruited by making social incentives salient). They had higher secondary school graduation exam scores overall and in natural sciences.
     
    Performance: During the first 18 months of work, CHAs recruited by making career incentives salient conducted 94 more household visits than those recruited in the social incentives group, who conducted an average of 319 visits. They did not achieve these gains by targeting easy-to-reach households or by spending less time on each visit. CHAs in the career benefits group also hosted more than twice as many community meetings (an average of 38 meetings, compared with 17 meetings in the community benefits group). The effect on performance was driven by high-performing CHAs in the career incentives group—workers who would not have been recruited if they had not seen materials emphasizing opportunities for career advancement.
     
    Retention: There was no evidence that career incentives improved performance at the expense of retention. During the first six months after the CHAs’ one-year commitment period, the number of dropouts was similar across both groups. None of the CHAs who left did so for a higher-ranking position within the Ministry of Health because the Ministry requires CHAs to work for two years before applying for promotion.
     

    The Role of Fees and Information in Healthcare Decisions in Mali

    Globally, considerable progress has been made in the past decades in reducing the child mortality rate, yet very high rates remain in many countries, most of them in Sub-Saharan Africa. In this study, researchers are evaluating the effects of providing free health care and free health care workers to children of poor families in Mali. They are measuring how the two programs, coupled together and provided individually, influence use of preventive care, the use of formal medical care, and the amount of time caregivers wait before seeking care for a sick child.

    Policy Issue:

    Many countries have succeeded in reducing their child mortality rates over the past two decades. The number of children in developing countries who died before they reached the age of five dropped from 100 to 72 deaths per 1,000 live births between 1990 and 2008. Still, every year almost nine million children die before they reach their fifth birthday. Many of these children, 43 percent, died from pneumonia, diarrhea, malaria or AIDS, and more than a third of all child deaths were related to under-nutrition.

    Policymakers and development organizations across the developing world have been striving to reduce the number of children that die before their fifth birthday by two-thirds by 2015, in accordance with the UN Millennium Development Goals. Not everyone agrees on the most effective, and most cost-effective ways to reach this goal, however, and much debate has surrounded the delivery and funding of primary healthcare for children. This study contributes much-needed evidence on what drives parents’ decisions about their children’s health care and the barriers they face in obtaining timely care for their children.

    Context of the Evaluation:

    Mali has shown considerable progress in addressing child mortality since 1990, essentially halving the proportion of children who die before the age of five. Despite this progress, health indicators in Mali remain poor, and infant mortality rates are still among the highest in the world, with 128 out of 1,000 children dying before age five.

    The Mali Health Organizing Project (Mali Health), the implementing partner in this study, aims to improve health care quality and access for people living in impoverished areas of Bamako. Founded in 2007, Mali Health works to deliver cost-effective results through community-driven, culturally appropriate, and sustainable approaches. This study will help the organization assess how to provide quality health services at an affordable cost to poor populations.

    Details of the intervention:

    To evaluate the impact of providing health care workers and free health care to families in Mali on use of preventive care, use of formal medical care vs. traditional healers, and the amount of time families wait before seeking care when their child is acutely ill, researchers are carrying out a randomized evaluation among low-income households in Sikoroni, near urban Bamako. Researchers randomly assigned 1,050 similar households into one of four groups and Mali Health implemented the programs.

    Healthcare worker only: Each family is assigned a locally recruited health worker, trained by Mali Health and employed full time. In biweekly visits, the health worker assesses the child's health according to a WHO-based protocol and advises the family if they should visit the clinic. The health workers also provide general information about good health practices and encourage preventive measures. These efforts focus on 13 Essential Family Practices as defined by the Malian government and include hand washing, bednet usage and water purification.

    Free healthcare only: Healthcare at the two local clinics is free for the enrolled children if their illness is due to malnutrition, malaria, vaccine preventable diseases, diarrhea, or acute respiratory infection, and can be treated at the community clinic. The average cost per clinic visit that Mali Health currently reimburses is about CFA6000, or roughly US$12

    Free healthcare and healthcare workers

    No intervention- comparison group

    Researchers collected detailed data on each child’s socio-economic background and used weekly visits over 7 to 10 weeks in two survey rounds in order to construct a complete health history detailing on a daily basis all symptoms that a child exhibited, and all healthcare sought by the family. Researchers are using data to pinpoint specific characteristics, identified during the initial survey period, that prevent families from seeking care, such as financial constraints, inability to borrow or save, insufficient information about health and healthcare, and/or different spending priorities.

    Results and Policy Lessons: 

    Results forthcoming.  

     

    Mark Dean, Anja Sautmann

    Nurse-led Screening and Counseling for Victims of Intimate Partner Violence in Mexico City

    In Mexico, one in four women have experienced physical and/or sexual violence by an intimate partner, and addressing violence against women remains a challenge across the world. Researchers in this study are evaluating the impact of a nurse delivered screening and counseling program on the frequency of and injuries from physical and sexual intimate partner violence, reproductive coercion, use of community-based resources and safety planning behavior, as well as the quality of life and mental health of women who have recently experienced such violence in Mexico City.

    Policy Issue:

    Thirty percent of women worldwide experience physical and/or sexual intimate partner violence sometime in their lifetime.[1] Research demonstrates that women who experience such violence undergo negative health consequences. Previous studies indicate these women are more likely to experience poor mental health; unwanted pregnancies; vulnerabilities to HIV and sexually transmitted infections; risk of antepartum hemorrhage and miscarriage; depression and suicide.  Given the high percentage of women of reproductive age affected by such violence, along with associated negative reproductive health consequences, health care providers can play a critical role in both assessing intimate partner violence in their patients and in mitigating related risks.

    While various policies have been implemented to strengthen the health care response to intimate partner violence, most robust designs have been conducted in industrialized countries such as the United States. To date, rigorous evaluations of the few existing health sector intervention efforts have not been conducted in a systematic manner in Mexico. Findings from this study will provide important insights into whether a nurse-delivered program can assist women currently experiencing partner violence in a Latin American context.

     
    Context of the Evaluation:

    One in four women in Mexico reports experiencing physical and sexual intimate partner violence.[2] For lower income women who experience sexual or physical abuse by a partner in Mexico City, nurses in government clinics are often their first point of contact with the healthcare sector. Training nurses to respond to cases of intimate partner violence may, therefore, increase midlevel health care providers’ capacity to identify cases and to assist these women with health risk mitigation.

    This study will inform partners, who include the Secretariat of Health of Mexico City, the National Institute of Public Health of Mexico, and the Mexican Foundation for Family Planning (MEXFAM), an International Planned Parenthood Federation affiliate, about effective programs and policies in Mexico City’s public health care facilities and at the national level.

     
    Details of the Intervention:

    To evaluate the impact of nurse-led screening and victim counseling on women who experience intimate partner violence, researchers designed a randomized evaluation, which is being implemented by the study team in government health clinics belonging to the Secretariat of Health of Mexico City. The study includes 952 women from 42 health care clinics. Half of the randomly assigned clinics are serving as the “intervention” group, while the other half are serving as a comparison group.

    The female participants are 18-44 years of age, either not pregnant or in their first trimester, and reported experiencing physical and/or sexual violence in the previous year in a heterosexual relationship.

    Nurses in the clinics assigned to the intervention group underwent a two-week training with refresher sessions on intimate partner violence, the health impacts of such violence, how to document cases, carry out safety planning and perform supported referrals. The comparison clinics offer a minimum standard of care from Mexico City’s government health facilities  (i.e., a referral card for victims only).

    Women who agreed to participate in the intervention group completed an initial survey and then received a 30-minute counseling session from a trained nurse. Those participants received a follow-up counseling session three months after the initial survey. Final data collection is taking place fifteen months after the initial survey.

    Researchers are asking participants in both groups about occurrence and injuries from severe physical and sexual violence by an intimate partner over the previous year; reproductive coercion; use of community-based resources and safety planning; and quality of life and mental health. Researchers will also conduct in-depth interviews with women and nurses from treatment and comparison clinics to gather qualitative data on which specific aspects of the program triggered any changes.

     
    Results and Policy Lessons:

    Results forthcoming.


    [1]WHO report 2013 http://apps.who.int/iris/bitstream/10665/85239/1/9789241564625_eng.pdf

    [2] Avila-Burgos, Leticia, Rosario Valdez-Santiago, Martha Híjar, Aurora del Rio-Zolezzi, Rosalba Rojas-Martínez, and Carlo E. Medina-Solís. "Factors associated with severity of intimate partner abuse in Mexico: results of the first National Survey of Violence Against Women." Can J Public Health 100, no. 6 (2009): 436-41.

    Jhumka Gupta

    Slum Housing Upgrading In El Salvador, Mexico and Uruguay

    Adequate housing is thought to provide a number of benefits, including greater satisfaction with one’s quality of life, better mental and physical health, protection against extreme weather, and improved safety and defense against crime. Researchers measured the impact of improving the quality of slum housing on household wellbeing in El Salvador, Mexico, and Uruguay, with IPA implementing the evaluation in Mexico. Residents were selected to receive housing upgrades by lottery. Results showed that slum upgrading significantly improved satisfaction with quality of life. In two countries positive and significant effects were detected in child health. In El Salvador, significant and positive effects were observed in the perception of safety. Finally, no effects were detected in labor market variables and in the accumulation of durable goods.

    Policy Issue:
    The United Nations estimates that nearly one billion people, primarily in the developing world, live in urban slums and lack proper housing.  Slum houses are typically made of waste materials such as cardboard, tin, and plastic, have dirt floors, and lack connections to basic services such as water and sewer systems. Adequate housing is thought to provide a number of benefits, including better mental and physical health, protection against extreme weather, and improved safety and defense against crime. Improved safety and security may, in turn, allow households to accumulate assets and free up time for productive activities that would otherwise be devoted to protecting these assets. Better housing can also affect individuals’ sense of dignity and satisfaction with their quality of life, which may complement improvements in other dimensions. One way to address the challenge of inadequate housing is to upgrade slum dwellings with inexpensive yet durable materials such as concrete floors or tin roofs. Despite the widely held belief that housing has an important role to play in improving health and welfare, there is little rigorous evidence about how housing improvement programs can affect the welfare of participants.
     
    Context of the Evaluation:
    This study as a whole measures the effect of a slum housing improvement program across three Latin American countries: El Salvador, Mexico, and Uruguay. Researchers partnered with IPA to carry out the evaluation in Mexico. 
     
    Slums in Latin America are typically found in dangerous geographic locations, such as on cliffs or slopes, and lack access to basic services such as water, electricity, and sanitation. Residents are also exposed to significant levels of soil and water contamination and overcrowding.
     
    Using baseline and national survey data, researchers identified several key differences between the slum populations and poor populations not living in slums. In particular, slum populations were worse off in terms of asset possession than other poor populations, which tend to have better access to basic services and higher quality housing. These differences were most pronounced in El Salvador, the poorest country in the sample.
     
    In Uruguay and Mexico, on the other hand, poor slum dwellers tended to have significantly higher incomes than poor non-slum dwellers. This could be because slums tend to form around large urban centers where there are more employment opportunities, and people who choose to live in slums may be more willing to accept worse living conditions in exchange for better access to the labor market. 
     
     
    Details of the Intervention:                                
    Researchers partnered with TECHO to evaluate the impact of upgrading housing infrastructure in urban slums in El Salvador, Mexico, and Uruguay, and IPA implemented the evalution in Mexico. TECHO is a youth-led non-governmental organization that works across nineteen Latin American countries to provide basic, pre-made houses to people living in slums. TECHO targets families living in sub-standard housing facilities and provides them with basic housing structures as a part of a package of social services designed to help lift households out of extreme poverty.
     
    The TECHO housing units are one-room houses made with insulated pinewood and tin roofs. Units are portable, constructed with simple tools, and can be set up by groups of 4-8 volunteers. Although TECHO units are a major improvement over the recipients’ previous housing, they still lack plumbing, sewage, and gas connections. The cost of each housing unit is approximately US$1,000 and beneficiary households are expected to contribute ten percent of the total cost. In El Salvador, this is roughly equivalent to 3 months of earnings, while in Mexico and Uruguay it is closer to 1.4 months of earnings.
     
    Informal settlements were eligible to receive TECHO housing if they had ten or more families living on public or private land and lacked access to one or more basic services such as electricity, water, or sewage. Within an eligible settlement, the poorest households were eligible to receive a housing upgrade. Due to budget and personnel constraints, TECHO conducted lotteries within eligible settlements to select which households would receive houses. From a sample of 2373 eligible households across all three countries, 1356 were randomly selected to receive housing upgrades and the remaining 1017 served as the comparison group. 
     
    Researchers conducted follow-up surveys between 17 and 27 months after households received the improved house and collected data on self-reported satisfaction, safety, and health as well as labor market outcomes and possession of durable goods. 
     
    Results and Policy Lessons:
    Impacts on quality of life: Families that received housing upgrades from TECHO were more satisfied with their homes and quality of life. Satisfaction increased by 15 percentage points across all three countries, a 29 percent increase over satisfaction ratings in the comparison group. Households in El Salvador experienced the largest gains in satisfaction with their homes, approximately 21 percentage points (41 percent), partially because self-reported levels of satisfaction were generally lower than in the other countries at baseline. 
     
    The program had no effect on households’ investments in their homes. Families did not make further investments in their homes in response to the TECHO improvements, and there were no significant improvements in access to water, electricity, or sanitation. 
     
    Impacts on security and safety: Households in El Salvador who received housing upgrade reported substantial improvements in their feeling of security. Recipient households were 18 percentage points more likely to feel safe inside their houses, 16 percentage points more likely to feel safe leaving their homes alone, and 14 percentage points more likely to feel safe leaving children alone at home. The program did not have any significant impact on perceptions of safety in Mexico or Uruguay. 
     
    Impacts on children’s health: In El Salvador and Mexico, child health improved as a result of the TECHO program. Households reported a four percentage point (27 percent) decrease in the incidence of diarrhea from a base of 15 percent. There were no statistically significant improvements in child health in Uruguay, perhaps because the experiment took place in slums that were more urbanized with better access to basic services. 
     
    Researchers concluded that providing better housing in urban slums was fairly inexpensive and substantially increased life satisfaction across multiple contexts. They suggest that upgrading homes in existing slums should be considered as an option in addition to relocating residents to new houses farther away from urban centers given residents’ potential preference for proximity to labor markets.

    The Role of Incentives in the Distribution of Public Goods in Zambia

    Policy Issue:

    Non-profit and public organizations increasingly rely on the services of community members to deliver and promote health goods. Community member involvement in the distribution of health goods can have significant benefits for the community at large, but only if the commitment and motivation of the community members is sustainable. While there is a significant literature on the role of incentives in the commercial sphere, there is little evidence on how various compensation schemes affect motivation when a task has a social benefit. Standard financial incentives that increase motivation in the commercial sphere may actually crowd-out intrinsic motivation for socially beneficial tasks, which may reduce overall performance. Alternatively, financial incentives may have little impact on performance if individuals drawn to mission-driven organizations place little weight on financial gains. Thus, the question of how to compensate community agents remains a challenge for many non-profit employers who hope to leverage this valuable community resource.

    Context:

    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.

    Temporary Labor Migration as Mitigation: Strategies for Managing Seasonal Famine

    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.

     
    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.

    Savings Accounts for Rural Micro Entrepreneurs in Kenya

    Testing the impact of formal savings accounts on savings, productive investment and expenditures among small-scale entrepreneurs in rural Western Kenya.

    Policy Issue:

    Hundreds of millions of people in developing countries earn their living through small-scale businesses with very low levels of working capital. Approximately a quarter  of households living on less than US$2 per day have at least one self employed household member. Enabling small-scale entrepreneurship has long been identified as a mechanism to alleviate poverty, and substantial attention has been paid to microcredit as a means to promote entrepreneurship. However, the impact of microcredit schemes on business outcomes, especially for the very poor, is still largely unknown, and many banks which target the poor realize low or negative profits. In this context, some have argued that the focus needs to be put on savings instead of credit, since evidence suggests that individuals should be able to save their way out of credit constraints. But this strategy demands accessible opportunities for people to save securely – an uncertain prospect for the vast majority of the poor who still lack access to formal banking services of any kind.

    Context of the Evaluation:

    In Kenya, small enterprises have been estimated to account for more than 20 percent of adult employment and 12-14 percent of national GDP, but only 2.2 percent of surveyed microentrepreneurs had a savings account with a commercial bank prior to the study. Some individuals have demonstrated a willingness to pay a premium to save securely, often receiving negative interest or tying their funds up in illiquid savings and credit associations. The fact that people take up these costly strategies suggests that the private returns to holding cash at home are even lower, possibly due to the risk of theft, appropriation by one’s spouse or other relatives, or because individuals tend to over-consume cash on hand.  In the village of Bumala, a market center along the main highway connecting Kenya to Uganda, a community-owned bank sought to increase access to formal banking by offering savings accounts to villagers. Still, two years after opening, only 0.5 percent of daily income earners had opened an account, citing lack of information about the bank and the inability to pay the account opening fee as primary reasons for low take-up.  

    Description of Intervention:

    Working in collaboration with the Bumala village bank, researchers studied the importance of savings constraints for self-employed individuals in rural Kenya. Field workers identified market vendors, bicycle taxi drivers, and self-employed artisans who did not already have a savings account, but were interested in opening one. Of the eligible individuals, 163 were randomly selected to be offered the option to open a savings account at no cost, with a minimum balance that could not be withdrawn. These accounts offered no interest and included substantial withdrawal fees. Thus, the de facto interest rate on deposits was negative. A comparison group of 156 individuals was not barred from opening an account but was offered no assistance in doing so.

    To test the prevalence and impact of savings constraints, researchers examined 279 self-reported daily logbooks kept by individuals in both the treatment and comparison groups. These logbooks included detailed information on market investments, expenditures and health shocks, making it possible to examine the impact of the savings accounts along a variety of dimensions. Field workers met with respondents twice per week to verify the logbooks were being filled out correctly, and paid respondents a small amount for each week the logbook was completed correctly. This information was supplemented with administrative data on savings from the bank itself.

    Results and Policy Lessons:

    Impact on Savings Account Take-up: Eight percent of respondents refused to even open an account, while another 39 percent opened an account but never made a deposit. Of those who did utilize the savings accounts, women made significantly larger deposits, a median of 100 Ksh,(US$1.42, equivalent to 1.6 times average daily expenditure) compared to the median deposits for men of 50 Ksh ($0.71).  This gender difference increased for those who deposited more.  Account usage was very strongly correlated with wealth, suggesting that the accounts were mostly useful for people above subsistence levels.

    Impact on Savings Behavior: Reported average bank savings were higher in the treatment group. Females in the treatment group did not decrease other forms of savings in animal stock and ROSCAs (informal groups that require members to make regular contributions to a savings pot that is periodically given to one member).  There are various possible explanations for the continued use of ROSCAs by women. It is possible that ROSCAs are valuable as a source of credit and emergency insurance; that they provide a form of savings commitment through social pressure; or that changes in ROSCA participation could not be captured during the study due to the long  savings cycles (up to 18 months).

    Impact on Business Investment: Four to six months after they were offered, bank accounts had substantial positive impacts on business investment for women, with a 37.5 percent increase in average daily investment. This suggests women faced large negative returns on money they saved informally, and those constraints were important for the businesses they run.  While very large on average, this treatment effect is also quite heterogeneous: only 57 percent of women in the treatment group made at least one deposit within the first 6 months of opening the account, and only 43 percent made at least two deposits within that timeframe.

    Impact on Private Expenditures: Findings suggest that higher business investment in the treatment group led to higher profits, as measured through household expenditures.  The accounts had a significant positive impact on expenditures on the entire sample, with this effect most strongly concentrated for market women. About 6 months after having gained access to the account, the daily private expenditures of women in the treatment group were on average 37 percent higher than those in the comparison group. Daily expenditure on food was also significantly higher.

     

    Understanding Male Fertility Preferences in Zambia

    Can male partners play a role in improving reproductive health among women in developing countries? Evidence suggests women are less likely to seek contraception if their husbands are present, but what if men are educated first about the risks of bearing multiple children close together? This evaluation in Zambia assesses whether providing men or women information on maternal mortality risks in addition to regular family planning information can change attitudes toward family planning and lower fertility rates by aligning fertility preferences between men and women. 

     
    Policy Issue: 
    As much as 50% of all pregnancies worldwide are unplanned or unwanted, accounting for nearly 300,000 new pregnancies every day. The ability to control fertility can have broad social and economic consequences since families experiencing unwanted pregnancies may find it harder to pay for their children’s education, healthcare and general wellbeing. Recent evidence suggests that access to contraceptives may improve economic outcomes and reduce poverty by allowing women to optimally time births, increasing investment in education and participation in the labor market at childbearing ages. There are also direct consequences for individual well-being: significant reported need for contraceptives suggests that people are having more children than they desire in many parts of the developing world. One possible reason is that in many countries men dominate decisions regarding sexual relations and contraception, and spousal discordance may influence fertility outcomes.
     
    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, and a similarly high infant mortality ratio with 92 deaths per 1,000 live births. 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.

    Nava Ashraf, Erica Field

    Improving Health Service Delivery Through Community Monitoring and Non-Financial Awards

    We know little about whether non-financial incentives can improve the performance of health care workers in countries with cash-strapped health systems. In this study, IPA introduced two types of non-financial incentives to randomly selected health clinics in Sierra Leone—a bottom-up community monitoring program and a top-down non-financial awards competition–-to measure the impacts different types of non-financial incentives can have on health worker performance.

     
    Policy Issue:

    In many developing countries, the health sector suffers from a severe human resources problem due to staff shortages and absenteeism. The availability of health care workers is a crucial element of quality care and the existing high levels of absenteeism represent a major leakage in health sector resources. Policy-makers have focused their attention on performance-based financing to incentivize attendance and performance monetarily; however, the evidence on the impact of financial incentives in improving performance in the health sector is mixed. While some programs report positive results, others show little to no effect on attendance and outcomes.

    In contrast, recent results have highlighted the power of non-financial incentives to reduce absenteeism and improve performance.  Evidence suggests that peer recognition and status-based incentives can be more motivational, less expensive and less likely to erode intrinsic motivation.[1]  In addition, another study implementing a community monitoring initiative in Uganda, in which community members and health workers jointly addressed obstacles to adequate healthcare provision. The study found that under-five mortality was 33 percent lower in treatment compared to comparison communities a year later, while utilization for general outpatient services was 20 percent higher.[2]

    Yet, the finding that non-financial incentives such as community monitoring improve clinic performance leaves a crucial question unanswered: does community monitoring improve clinic performance because it is a bottom-up intervention which makes clinic personnel socially accountable to their immediate neighbors? Or does it work simply because clinic performance is being monitored and evaluated? The answer to this question is important as top-down monitoring may be potentially cheaper and more efficient than bottom-up monitoring; however, data on this crucial question is lacking.

    Context of the Evaluation:

    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



    [1]Ashraf, Nava, Oriana Bandiera, and Kelsey Jack. "No Margin, No Mission? A Field Experiment on Incentives for Pro-Social Tasks." Harvard Business School Working Paper, No. 12-008, August 2011.

    Conditional Cash Transfers and HIV/AIDS Prevention in Malawi

    Conditional cash transfers, where money is given to individuals on certain conditions, have been used successfully to incentivize families to send their children to school, to encourage people to get preventive healthcare check-ups, and to change other behaviors. In this study, researchers evaluated if financial incentives could motivate safer sexual behavior. In Malawi, where 11 percent of adults are infected with HIV/AIDS, participants were offered different sums of money to maintain their negative HIV status for one year. The promise of financial incentives of any amount—even four months of wages—had no effect on subsequent sexual behavior, pregnancy or HIV status. However, after receiving the monetary reward, men were significantly more likely to have engaged in unprotected sex. Women were significantly less likely to have had unprotected sex after receiving the money. The results suggest that policymakers should use caution in considering conditional cash transfers as a tool for HIV prevention.

    Policy Issue: 
    At the end of 2009, more than 33 million people were living with HIV. Given the extent of the HIV/AIDS epidemic, policymakers face an urgent need to develop effective treatment and prevention programs. While most HIV prevention strategies target behavior change, evidence of the impact of these programs remains controversial and no single intervention has emerged as an established approach. Conditional cash transfers (CCTs) have been used successfully in a variety of settings as a means of incentivizing socially desirable behavior change, such as school enrollment or attendance at preventive healthcare check-ups. There is some evidence that CCTs could be used to prevent the spread of HIV by incentivizing individuals to stay free of sexually transmitted diseases, however more evidence is needed to understand responses across various contexts and populations.
     
    Context of the Evaluation: 
    Eleven percent of adults in Malawi are infected with HIV/AIDS, giving the country the 9th highest prevalence in the world.1 Although the HIV prevalence rate in the sample area was considerably lower than the national rate, at 6.3 percent, it was comparable to, or greater than, the prevalence rate in much of sub-Saharan Africa. For comparison, in 2009, the HIV prevalence rate in Kenya and Sierra Leone was 6.3 percent and 1.6 percent, respectively.
     
    Existing research suggests that CCTs may be an effective method to reduce sexual behavior and prevent HIV. In Tanzania, a program that offered cash incentives for remaining free of curable sexual transmitted infection (STIs) led to a significant reduction in STI infections when participants were offered a large transfer (US$20). However, the program had little impact when participants were offered a moderate transfer (US$10). A second study in Malawi offered girls and their parents US$15 each month to attend school, in addition to covering all school fees. After one year, girls offered the unconditional incentives were significantly less likely to be infected with HIV.ii
     
    Details of the Intervention: 
    Researchers sought to evaluate whether offering individuals financial incentives to maintain their HIV status could be an effective HIV prevention strategy in rural Malawi. Researchers measured the impact of conditional cash transfers (CCTs) on reported sexual activity, condom use, and incidences of HIV infection. The CCT program builds upon a previous evaluation of the Malawi Diffusion and Ideational Change Project (MDICP), where respondents were offered free door-to-door HIV testing and randomly assigned cash incentives to obtain their results from nearby testing centers.
     
    Among MDICP participants that agreed to be tested for HIV in 2006, 1,307 were randomly invited to participate in the CCT program. Seventy-six percent of the sample enrolled as individuals, while the remaining enrolled as couples. Participants were offered incentives of random amounts ranging from zero to 2,000 MWK (approximately US$16) for individuals, and from zero to 4,000 MWK (approximately US$32) for couples, all of which were conditional on maintaining their HIV status for approximately one year. The incentives represented a significant amount of money for respondents, with the higher amount equal to approximately three to four months wages. 
     
    Throughout the year, program staff visited participants in their homes and asked about their sexual behavior in the last nine days through interview-administered sexual diaries. From these diaries, researchers developed several indicators of risky or safe sexual behavior, including pregnancy, incidents of vaginal sex, number of days having vaginal sex, condom usage, and the presence of condoms at home. Data was collected three times over the period of the study, at roughly three-month intervals. After the last round of surveys, a trained nurse visited each participant to test for HIV, and financial incentives were awarded based on whether they had maintained their HIV status. Approximately one week later, each respondent was surveyed again about his/her sexual behavior in the past week.
     
    Individuals who were HIV-positive at the start of the program automatically received the monetary incentive at the end of the study. These individuals were included in the sample to avoid the possibility that being excluded from the study would signal their HIV positive status to outsiders.
     
    Results and Policy Lessons: 
    The promise of financial incentives of any amount had no effect on subsequent self-reported sexual behavior or HIV status. Self-reports may be biased towards individuals over-reporting safe sexual behavior, particularly for individuals receiving higher incentives. Despite these potential biases, which would lead to an overestimation of program impact, financial incentives appear to have had no effect.
     
    Although the conditional offer of money had no impact, receiving cash after the final round of HIV testing was found to have large effects on respondents' self-reported behavior. In the week following the receipt of the cash transfer, men who received the money were 12.3 percentage points more likely to have had vaginal sex and had approximately 0.5 more days of sex. While self-reported condom use among these men increased by 6.9 percentage points, overall, they were 9 percentage points more likely to engage in riskier sex. Women, on the other hand, were 6.7 percentage points less likely to report engagement in risky sex, a result that is driven by abstinence rather than increased condom use.
    These results provide evidence that money given in the present may have much stronger effects than rewards in the future. Unlike the CCT program in Tanzania, this study found no effect of financial incentives on risky sexual behavior, suggesting that policymakers should use caution in considering CCTs as a tool for HIV prevention. The fact that a cash grant reduced risky sexual behavior for women provides further evidence that money can be protective for women, but cautions that programs that aim to motivate safe sexual behavior in Africa may be sensitive to the local and/or cultural context, and the degree of agency individuals to determine their own sexual behaviors.
     
    i UNAIDS (2010) “UNAIDS Report on the Global AIDS Epidemic.” www.unaids.org/globalreport/Global_report.htm
    ii Baird, Sarah, Craig McIntosh, and Berk Ozler. 2011. "Cash or Condition? Evidence from a Cash Transfer Experiment." The Quarterly Journal of Economics 126(4): 1709-1753.
     
    Related Papers Citations: 
    Kohler, Hans-Peter, and Rebecca Thornton. 2011. "Conditional Cash Transfers and HIV/AIDS Prevention: Unconditionally Promising?" World Bank Economic Review 26(2011): 165-190.
     

     

    Rebecca Thornton

    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.http://www.who.int/whosis/whostat/EN_WHS2011_Full.pdf

    Mushfiq Mobarak

    Community-Based Monitoring of Primary Healthcare Providers in Uganda

    Policy Issue: 
    Nearly 11 million children under five die each year, many from preventable diseases such as pneumonia, malaria, and measles. Though prevention and treatment for such diseases is relatively cheap, many do not have access to the necessary services. One possible reason for this may be ineffective systems of monitoring and weak accountability relationships between the service providers and those whom they are serving. Poor incentives for public providers to deliver quality services may result in high absenteeism and low-quality patient care. Participation of beneficiaries in the monitoring of public service delivery may be important for improvement, given that they have the most to benefit from improved health services.
     
    Context of the Evaluation: 
    Uganda, like many newly independent countries in Africa, had a functioning healthcare system in the early 1960s, but saw a collapse of government services as the country underwent political upheaval. The government has been implementing major infrastructure rehabilitation programs in the public health sector, but improved outcomes have remained elusive.
     
    Rural dispensaries, which are the lowest tier of the Ugandan health system, provide preventive outpatient care, maternity, and laboratory services. A number of actors are responsible for supervision and control of the dispensaries including the Health Unit Management Committee, who monitor the day-to-day running of the facility, but have no authority to sanction workers. The Health Sub-district, one level above, is supposed to monitor funds, drugs, and service delivery, but this monitoring is infrequent. Only the Chief Administrative Officer of the District and the District Service Commission have the authority to suspend or dismiss staff. Usually staffed by one medical worker, two nurses, and three aides, dispensaries provide no incentives for their workers to increase their efforts. 
     
    Details of the Intervention: 
    Researchers conducted a randomized evaluation at 50 dispensaries from nine districts in Uganda to see if community monitoring could impact health worker performance and subsequent health utilization and outcomes. 
     
    In the area around 25 randomly selected dispensaries, local NGOs facilitated three sets of meetings. In the first, approximately 150 community members, both the disadvantaged and the elite, discussed the status of their health services and means of identifying steps the providers should take to improve health service provision. Second, a provider staff meeting was held to contrast the citizen’s view on service provision with that of the health worker. The third, an interface meeting, allowed community members and health workers to discuss patient rights and provider responsibilities. The outcome was a shared action plan, or a contract, outlining the community’s and the service provider’s agreement on what needs to be done, how, when, and by whom. These three sets of meetings aimed to kick-start the process of community monitoring. After six months, community and interface meetings were held to review progress and suggest improvements. 
    A survey was administered to both the service providers and a randomly selected subset of households around each dispensary prior to the intervention and again one year later. This information was supplemented by administrative records and visual checks of the dispensary.
     
    Results and Policy Lessons: 
    Impact on Quality Care: A year after the first round of meetings, health facilities in treatment villages were 36 percent more likely to have suggestion boxes and 20 percent more likely to have numbered waiting cards, relative to the comparison facilities. There was a 12 minute reduction in wait time, a 13 percentage point reduction in absenteeism, and the overall facility cleanliness of the facility improved. 
     
    Impact on Health Outcomes: Utilization of general outpatient services was 20 percent higher in the treatment group. Specficially, 58 percent more people came for child birth deliveries, 19 percent more patients sought prenatal care, number of patients seeking family planning increased by 22 percent, and immunizations increased for all age groups, especially newborns. Households also reduced the number of visits to traditional healers and the extent of self-treatment. Relative to the comparison group, intervention communities saw a 0.14 z-score increase in infant weight and a 33 percent reduction in the mortality of children under 5 years old. Variation in treatment intensity across districts shows a significant relationship between the degree of community monitoring and health utilization and outcomes.
     
    Related Papers Citations: 
    Bjorkman, Martina, and Jakob Svensson. 2009. "Power to the People: Evidence From a Randomized Field Experiment on Community-Based Monitoring in Uganda." The Quarterly Journal of Economics 124(2): 735-69.

     

    Demand for Nontraditional Cookstoves in Bangladesh

    Demand for nontraditional cookstoves in Bangladesh is very low. While women—who bear disproportionate responsibility for cooking—have stronger preferences for improved stoves, they lack the authority to make purchase decisions.

    Policy Issue: 

    One half of the world's households, and 75 percent of people in South Asia, burn biomass fuels, such as wood, leaves, dung, and peat, for energy. The smoke released from using such fuels has been shown to lead to respiratory diseases and lung cancer, which disproportionately affects women, who are primarily responsible for cooking, and the young children they are caring for. According to the World Health Organization (WHO), indoor air pollution is the single largest risk factor for female mortality. Among the entire population, indoor air pollution is responsible for nearly two million deaths annually. In response, NGOs and governments have distributed tens of millions of "improved" or "clean" stoves, but the adoption and use of these nontraditional cookstoves in the developing world has, with few exceptions, remained extremely low.

    Context:

    Since the early 1980s, over 100 national and local organizations have developed and attempted to distribute a variety of nontraditional cookstove models tailored to the local needs in Bangladesh. Despite such efforts, 98 percent of the population in rural Bangladesh continues to cook with traditional biomass-burning stoves. A survey conducted in 2006 suggests that women in rural Bangladesh do not perceive indoor air pollution as a significant health hazard and subsequently prioritize other basic development needs over nontraditional cookstoves. When asked to rank the relative desirability of different attributes of nontraditional cookstoves, 47 percent of households cited the ability of nontraditional cookstoves to reduce fuel costs as their most valuable characteristic. The next most-valued attributes were the ability to reduce cooking time (21 percent) and to accommodate a wider variety of biomass fuels (14 percent). Only 9 percent of respondents answered that reducing or eliminating household smoke was the most valuable attribute.

    Description of Intervention:

    In order to explore households’ preferences, researchers designed two sets of overlapping experiments, both of which provided respondents an opportunity to purchase a nontraditional cookstove. In 2008, households in rural Bangladesh were randomly selected to receive basic health education about the harm of traditional cookstoves and the benefits of nontraditional cookstoves. Afterwards, they were given the opportunity to buy either an efficiency stove that improves fuel efficiency, or a chimney stove that reduces exposure to indoor smoke; the specific details of the offer varied by treatment group.

    Each set of experiments was designed to evaluate the relative importance of two common explanations for the low adoption rates: (1) intrahousehold differences in preferences, and (2) lack of information from a trustworthy source about the new technology. For the first set of experiments, households were randomly assigned to one of the following treatment groups:

     

    Group

    Stove Offer

    Offer Recipient

    I

    Choice of Free Chimney or Efficiency Stove

    Husband

    II

    Choice of Free Chimney or Efficiency Stove

    Wife

    II

    Choice of TK250 (US$3) Chimney or TK50 (US$0.61) Efficiency Stove

    Husband

    IV

    Choice of TK250 (US$3) Chimney or TK50 (US$0.61) Efficiency Stove

    Wife

    A team of two enumerators visited each household. While one enumerator interviewed the male household head, the other conducted a separate interview with his wife. After completing the survey, either the husband or wife (depending on the treatment group) was given the opportunity to purchase either type of nontraditional cookstove, but was not able to consult with his/her spouse before making the decision.

    The second set of experiments tested a common social marketing strategy for disseminating credible information about a new technology. Specifically, it paired random variation in prices and stove type with information about the purchase decisions of village “opinion leaders.” In selected village, within each distinct neighborhood, researchers identified three opinion leaders. These opinion leaders were the first to be offered stoves, and their adoption decisions were then announced in the village. The detailed breakdown of the treatment groups was as follows:

     

    Group

    Opinion Leader

    Stove Type

    Stove Price

    V

    No information

    Chimney

    Full (TK750, US$11)

    Efficiency

    Full (TK400, US$5.80)

    VI

    No information

    Chimney

    Half (TK375, US$2.44)

    Efficiency

    Half (TK200, US$4.57)

    VII

    Publicized adoption decisions

    Chimney

    Full (TK750, US$11)

    Efficiency

    Full (TK400, US$5.80)

    VIII

    Publicized adoption decisions

    Chimney

    Half (TK375, US$2.44)

    Efficiency

    Half (TK200, US$4.57)

    Roughly four months after the orders were placed, project staff returned to deliver the cookstoves. At that time, households could refuse to install or pay for the stove.

    Results:

    Intrahousehold differences in preferences: Women seemed to exhibit a stronger preference than men for any improved stove, in particular for the health-saving chimney stoves. When the marketing offer was made to the wife rather than the husband, orders for the healthier chimney stove increased by 11.3 percentage points. This is consistent with the fact that the health cost of indoor smoke is greater for women. However, when a small positive price was charged for either stove, women became marginally less likely than men to order a stove. This may indicate that despite their preferences, women lack authority to make purchases.

    During the initial offer, individual choices were kept hidden. However, in the intervening period between stove order and stove purchase, husbands and wives had the opportunity to learn about each other’s choices and preferences, more generally. During this time period, women's choices seemed to converge with their husbands. At the final purchase stage, any gender difference in stove orders had disappeared. Again, it seems as if women could not act on their preference for improved cookstoves when their choice could subsequently be undone by their husband.

    Information dissemination:Receiving external information from opinion leaders seemed to matter more when the costs and benefits of technology were not readily apparent. Opinion leader influence on households’ purchase decisions was significantly less for chimney stoves, whose value in removing indoor smoke was apparent, than for efficiency stoves, whose combustion properties were much less obvious.

    When the initial stove orders were made, there was very limited information about the new technologies available in the village except for the opinion leader purchase decisions. After orders were placed, the cookstoves were delivered over a period of several weeks and consequently, those receiving cookstoves later could learn from those who received deliveries early. Subsequently, the value of the information acquired from the opinion leaders' choices declined over time, even for efficiency stoves. These results suggest that social marketing programswhich often attempt to use opinion leader influence to increase the adoption of health technologiesare likely to be less effective in the long run as common experience with technologies grows.

    Price effects: Reducing cookstove prices by 50 percent increased the number of orders and purchases of efficiency stoves by 25 and 11.6 percentage points, respectively. In contrast, orders for chimney stoves did not change significantly in response to changes in the price; the 50 percent subsidy only increased the order rate from 31.4 percent to 34.5 percent. Such marked differences in price elasticity suggest that in ordering stoves, households were less willing to trade off smoke emissions and health than they were the cook’s time and fuel costs.

     



    [i] World Health Organization (WHO). Global Health Observatory. Available at http://www.who.int/gho/phe/indoor_air_pollution/burden_text/en/index.html.

     

    Mushfiq Mobarak

    Communal Sanitation Solutions for Urban Slums in Orissa, India

    Can improved toilet facilities, combined with innovative accountability systems for maintenance, increase the use of community toilets in urban India?

    Policy Questions:

    In densely populated and rapidly growing countries, severe space constraints, poor utilities infrastructure, and temporary housing construction can render private household sanitation facilities infeasible. Improving communal toilets, which serve entire neighborhoods, may be a more feasible way to improve sanitation, health and well-being in such densely populated areas. However, these kinds of facilities face their own set of problems. Because the benefits of cleaner facilities extend beyond the individual, people may be unwilling to help with repair and maintenance. When the toilets then fall into disrepair, people often revert to open defecation, leading communal toilets to be abandoned. Can innovative systems of facility management help overcome these “collective action” problems and make communal toilets a sustainable option in urban slums?

    Evaluation Context:

    In the slums of Bhubaneswar and Cuttack in India, almost 45 percent of households use either public toilets, which are meant for a rotating population in commercial areas, or communal toilets, which serve a fixed residential population. However, the condition of these facilities is very poor. A preliminary survey showed that 53 percent of these toilets were either “dirty” or “very dirty”, and one in six facilities was completely non-functional. Households who were dissatisfied with the cleanliness of their community’s toilets were more likely to practice open defecation, and almost 30 percent of households reported doing so. Qualitative research suggests that these poor conditions may be caused by weak systems of accountability for toilet maintenance and repair.

    Details of the Intervention:

    This program sought to improve the physical infrastructure of community and public toilets, as well as to improve the associated management systems in order to ensure long-term maintenance. The physical infrastructure of a set of existing community toilets and a smaller set of existing public toilets will be updated to ensure that all have an adequate number of gender-separated toilets and washbasins; sufficient lighting and ventilation; and enough water for all services. A set of new toilets will also be constructed to these standards. A randomly chosen subset of both the community and public toilets will also be given enhanced, infrastructure, such as a space for bathing. Half of the improved community and public toilets, including both those with and without the enhanced infrastructure, will be randomly selected to be maintained by a private firm, while the remainder will be managed by the community according to a “constitution” that specifies responsibilities and rights.

    In order to identify a solution that will produce the most attractive, sustainable and hygienic alternatives to open defecation for slum residents, researchers will test a variety of complementary household-level interventions, such as discount coupons for shared facilities and varying the pricing structure (monthly passes vs. pay-per-use). Researchers will also conduct a program of demand generation activities in a subset of communities around community and public facilities. These activities will be used to help communities notice the problems associated with open defecation and develop community cohesion to sanction it.

    Researchers will collect data to measure take-up and maintenance of sanitation facilities over the life of the program. Household surveys will be used to examine satisfaction with the facilities, instances of diarrheal disease, and differential access within the household.

    Results & Policy Lessons:

    Project ongoing, results forthcoming.

    HIV Prevention Among Youths: Evidence from a Randomized Controlled Trial in Kenya

    Policy Issue: 

    The vast majority of new HIV infections occur in sub-Saharan Africa, where nearly 2 million people become infected with HIV/AIDS every year. Forty-five percent of these new HIV infections occur among people under 25 years old, and nearly all of them are due to unprotected sex. Ensuring the adoption of safer sexual behavior among youth is critical to keeping the new generations free of HIV.

    The objective of this project is to examine, through a large randomized controlled trial, the impact of two HIV prevention strategies among a youth population in Kenya. The two strategies to be tested are: Voluntary Counseling and Testing for HIV (VCT), and condom distribution.

    • VCT is a critical entry point for access to HIV/AIDS treatment and care, and is being scaled up in many countries. But VCT could also be a powerful prevention tool. By providing personalized counseling as well as information about high-risk behaviors, VCT could motivate people to adopt safer sexual behavior and prevent transmission of HIV. This could be particularly important for adolescents and young adults, who typically have had their sexual debut but might not have perfect information about HIV risk. They are often still HIV-negative, and might be better able to change their sexual behavior.

    • Despite strong evidence of the biological effectiveness of the male condom as an HIV prevention strategy, condom use continues to remain low in many countries. Several factors, such as low availability, cost, lack of education about condoms and how to use them, and relationship factors contribute to low usage.  This study examines whether free and easy access to a large quantity of condoms can result in a reduction of risky behaviors and a decline in transmission of STIs among youth.

    Context of the Evaluation: 

    Kenya has the 10th largest HIV infected population in the world – nearly 7% of Kenyans are infected.1 The study is being implemented in four districts of Kenya’s Western Province (Butere, Mumias and Bungoma South and Bungoma East), spanning an area of approximately 50,000 square kilometers. Since about 45% of all new infections worldwide occur in youth aged 15-24 years, this study focuses on young people (both men and women). The sample is composed of approximately 10,000 youths (half of them female) who were 17 to 22 years old in 2009.

    Despite the expanding implementation of VCT, an estimated 80% of Kenyans living with HIV are unaware of their status. Take-up of VCT in traditional settings (such as government health centers) is low. As such, several alternative models of VCT service provision, including mobile VCT, workplace VCT and home-based VCT are being explored. This study has used both mobile VCT and VCT within homes, and has achieved a very high take-up (85% of the people who were offered VCT accepted it).

    Condom usage in Kenya is also relatively low. Only 24% of women aged 15-49 who reported multiple partners in the last 12 months used a condom during their last sexual encounter. Despite significant efforts to increase availability of free male condoms, recent data suggest that condom distribution remains low, with on average 0.71 condoms distributed per eligible person per year.

    Details of the Intervention: 

    A detailed baseline survey was administered to 10,420 youths (about ½ of them girls) between March 2009 and July 2010. All respondents were tested for Herpes (HSV-2) and for HIV (via anonymous linked testing) during the baseline. The prevalence rates for HSV-2 and HIV were 8.5% and 0.5%, respectively.

    Among those surveyed at baseline, 25%  had been randomly pre-selected to be offered VCT, 25% had been randomly pre-selected to receive free condoms, and 25% had been randomly pre-selected to receive both VCT and free condoms.

    Those pre-selected for VCT were offered VCT right after the baseline survey had been administered. Eighty-seven percent of them consented.  The consent rate was slightly higher among girls than among boys.

    Those pre-selected for free condoms were offered three boxes of 50 condoms each, right after VCT (if also sampled for VCT) or right after the baseline survey had been administered. Not all respondents offered condoms took them. Seventy-one percent took all 150 condoms, 19% took only some of them, and the remainder, 10%, refused to take any condoms. The acceptance rate was much higher among boys. While 87% of boys took all the condoms and only 5% took none, only 52% of girls took all 150 condoms and 15% took none.

    A follow-up survey will be conducted in 2011-2012. The survey will include detailed questions on sexual behavior, including sexual debut, number and type of partners, and condom use, as well as detailed questions on beliefs regarding HIV transmission, own HIV status, and own exposure to risk. Crucially, the follow-up survey will also include HSV2 and HIV testing.

    Results: 

    Results forthcoming.

    1 CIA World Factbook, “Kenya”. Available at https://www.cia.gov/library/publications/the-world-factbook/geos/ke.html

    Improving Immunization Rates Through Regular Camps and Incentives in India

    Every year 2 to 3 million people die from diseases which could be prevented by existing vaccines. In India, immunization services are offered free in public facilities, but the immunization rate remains low. This study found that offering families small, non-financial incentives in addition to reliable services and education is a cost-effective method of increasing uptake of vaccinations.

    Policy Issue:

    Immunization is a highly cost-effective way of improving child survival, however, every year an estimated 2 to 3 million people die from vaccine-preventable diseases. High absenteeism rates among healthcare providers and unreliable supplies of vaccines may contribute to low vaccination rates in many developing countries. A lack of understanding of the benefits of vaccination or even a suspicion of government health services have been raised as possible contributing factors. Conditional cash transfers have been found to be effective in raising immunization rates, but these programs are very expensive and have mainly been tested in areas where health services are relatively well functioning. Can relatively small incentives have a big impact on immunization rates or — when immunization rates are very low — is the hostility too deeply rooted to be impacted by a small incentives? How much of the problem is just unreliable supply?

    Context of the Evaluation:

    In India, immunization services are offered free in public health facilities, but the immunization rate remains low. According to the National Family Health survey, only 44% of children aged 1-2 years old have received the basic package of immunizations. That rate drops to 22% in rural Rajasthan, and the data are likely to overstate immunization rates. Careful probing found only 2% of children had received the full package of immunizations in mostly tribal villages in rural Udaipur district.

    The public facilities serving these areas are characterized by high absenteeism: 45% of health staff who carry out immunizations (Auxiliary Nurse Midwives, or ANMs) are absent from their village-level health center (and could not be found anywhere in the village) on any given workday, with no predictable pattern to their absences. Given that a full immunization course requires at least five visits to a public health facility, the unreliability of the ANMs increases the opportunity cost of a visit to the sub-center and may deter families from taking their children to complete their full immunization schedule.

    Details of the Intervention: 

    This study assesses the relative efficacy and cost-effectiveness of improving the supply of infrastructure for immunization, and improving supply and simultaneously increasing demand through the use of modest, non-cash incentives. Two interventions were evaluated in rural Udaipur, and a third set of randomly selected villages served as the comparison group.

    • Intervention A:  Seva Mandir (a local NGO) hired a mobile immunization team including an ANM and assistant to conduct monthly immunization camps in villages. The camps were held from 11am - 2pm on a fixed date of the month and the presence of the ANM was verified by timed and dated photographs of them in the villages, as well as regular monitoring. Records indicate that 95% of planned camps took place, and were not disrupted by provider absence. A Seva Mandir social worker who lived in each village informed mothers of immunization camp availability and educated them on the benefits of immunization. The vaccine package administered was the WHO/UNICEF Extended Package of Immunization (EPI), which is the package provided by the Indian government. At the first immunization, every child was given an official immunization card indicating name, parent’s name, and the date and type of each immunization performed. When a child arrived at a camp without an immunization card and it could not be ascertained whether they had received a given immunization, he or she was immunized.
    • Intervention B: Using the same immunization camp infrastructure as intervention A, intervention B also offered parents 1 kg of lentils per immunization administered, and a set of thalis (metal meal plates) upon completion of a child’s full immunization course. The value of the lentils was about Rs. 40 (less than one dollar), equivalent to three quarters of one day’s wage. The incentives were provided as an agent to help offset the opportunity cost of taking a child to be vaccinated. Compliance with the full course of immunizations was verified by the child’s health card.
    Results and Policy Lessons:

    Incidence of full immunization (child received 5+ vaccinations): Among children aged 1-3 years, 38.3% were fully immunized in intervention B villages, compared to 16.6% in intervention A villages, and 6.2% in control villages. A child was 6.19 times as likely to be completely immunized in intervention B villages as in control villages, and 2.69 times as likely to be immunized in intervention A villages relative to control villages. 
    Children in areas neighboring intervention B villages are also more likely to be fully immunized relative to those in areas adjacent to intervention A villages (20% vs. 10%), suggesting that reliable camps with incentives also prompted parents from farther away to get their children immunized.

    Study results indicate that offering families in resource-poor settings small, non-financial incentives in addition to reliable services and education is more effective than providing services and education alone. It is also more cost effective—more children utilize immunization facilities, lowering the cost per child immunized, even considering the cost of the incentives. The average cost per child completely vaccinated was $27.94 in intervention B villages, relative to $55.83 in intervention A villages.

    Teacher Training and Free Uniforms for HIV Prevention in Primary Schools in Kenya

    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 10th 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.


    [i] CIA World Factbook, “Kenya” https://www.cia.gov/library/publications/the-world-factbook/geos/ke.html (accessed August 25, 2009). 

    Source Dispensers and Home Delivery of Chlorine in Kenya

     

    Policy Issue: 

    Diarrheal diseases are a leading cause of morbidity and mortality in the developing world, killing an estimated 2.6 million people per year between 1990 and 2000. Children under 5 experience an average of 3.2 diarrheal episodes per year1 and diarrheal diseases account for 20 percent of deaths in this age group.2  Even when diarrheal episodes are not fatal, they can have long-term impacts on children’s cognitive and physical development. Diarrheal diseases are often transmitted when a water supply is contaminated with fecal matter, and may be endemic in places where the water supply is irregular. Practices from handwashing to water source protection are proven to reduce diarrhea episodes, yet the adoption of such practices has been slow in regions across the developing world.

     
    Context of the Evaluation: 

    Despite widespread awareness of the dangers of drinking unsafe water, there is extremely low adoption of sanitation or clean water practices in rural Western Kenya. While three quarters of households have heard of point-of-use water chlorination and 70 percent admit that drinking dirty water causes diarrhea, only 5 percent of households report that their main drinking water supply is chlorinated. The most common method of water chlorination is through the individual purchase of chlorination products, which must be added to water at home. Community level chlorination has been considered as another strategy to increase chlorine take up. Much cheaper than individually packaged bottles, point-of-collection chlorine dispensers can be used at the sources where people collect their water. Here, social pressure may be maximized by making each individual’s sanitation choice publicly known.

     
    Details of the Intervention: 

    Researchers sought to examine the impact of factors including price, persuasion, promotion and the chlorination products themselves with a two-phase study. Prior to the study baseline surveys were administered to a random selection of households.

    In the first phase, households were given seven WaterGuard bottles, an individual water treatment product, each sufficient for one month’s supply of clean water. They were also provided with improved drinking water storage pots with a tap to prevent contamination and detailed instructions on use. One third of this group received twelve coupons for a 50 percent discount on WaterGuard bottles, each valid for one month during the next year, and calendars with reminders. Another 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, allowing researchers to see if higher community levels of use increased individual adoption. A follow-up survey was administered between 2 and 7 months after the free WaterGuard was distributed.

    In the second phase researchers compared six different treatments designed to increase WaterGuard adoption. For the first three treatments, scripted promotional messages were delivered at either the (1) household level, (2) community level, or (3) both. The second two treatments included repeated promotion of chlorination through a home visit by a community elected promoter. Despite volunteering to work for free, the promoter was paid either a (4) flat rate, or was (5) paid based on how many households had chlorinated water at follow-up visits. The last treatment (6) combined the incentivized promoter model with an unlimited supply of free WaterGuard delivered through a point-of-collection chlorine dispenser at the local water source. Follow-up surveys were conducted 3 weeks and 3-6 months after the start of the study.

     
    Results and Policy Lessons: 

    Impact of Free Home Distribution: Most households have a low willingness to pay for chlorine, despite its well known benefits. After receiving a free 7-month supply, chlorine was detected in 58 percent of households, much more than the 2 percent starting level. Still, only 10 percent of the distributed coupons were redeemed. Where WaterGuard bottles were distributed freely, additional persuasive messages had no effect on take up, and in retail markets they only had short-term effects. There appeared to be no “social networking” effects of living in a community with a higher level of chlorination, and no evidence was found that price was an effective screening mechanism to target households who are more likely to benefit from cleaner water.

    Impact of Persuasion: Hiring local community members at a low wage to promote chlorine use among their neighbors is highly effective at increasing use. Chlorine was detected in 40 percent of households visited by a promoter, compared to only 4 percent in those who weren’t visited. Incentivizing these promoters had only modest effects. Communities with point-of-collection chlorine dispensers in combination with promoters saw 61percent of households chlorinate their water, up from only 2 percent prior to the study, suggesting that this is a highly cost-effective way to promote take up.

    Scale-Up: Investments in marketing campaigns and coupon schemes proved to be ineffective strategies to encourage point-of-use chlorination. Free chlorination dispensed at water sources along with community promoters provided the most effective strategy to improve water cleanliness, potentially preventing diarrheal incidence in areas such as rural Kenya.

     

    1 Disease Control- Priorities Project, “Public Health Significance of Diarrheal Illnesses,” http://www.dcp2.org/pubs/DCP/19/Section/2531.

    2 Parashar, Umesh, et al. “Global Illness and Deaths Caused by Rotavirus Disease in Children,” Emerging Infectious Diseases. Vol. 9. May, 2003.

    Cleaning Natural Springs in Kenya

     

    Policy Issue: 

    Diarrheal diseases are a leading cause of morbidity and mortality in the developing world, killing an estimated 2.6 million people per year between 1990 and 2000. Children under 5 experience an average of 3.2 diarrheal episodes per year,1 which accounts for 20 percent of deaths in this age group.2 Even when diarrheal episodes are not fatal, they can lead to severe dehydration and have long-term impacts on children’s cognitive and physical development. Diarrheal diseases are often transmitted when a water supply is contaminated with fecal matter, and may be endemic in places where the water supply is irregular.

     

    Context of the Evaluation: 

    Diarrhea is widespread in rural Kenya, where 43 percent of the population gets their drinking water from nearby springs, usually transported in 10 to 20 liter jerry-cans. Landowners have no incentive to improve the sanitation of water sources on their property because custom requires them to allow everyone free access to springs. As such, water is often contaminated by surface rainwater runoff as it seeps from the ground, and this contamination is spread to the population who collect drinking water at the spring. However, people are often reluctant to change their habits to include behaviors that may reduce diarrhea incidence such as hand washing or daily chlorination of water, resulting in low uptake for these “point of use” interventions.

     
    Details of the Intervention: 

    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 percent of the costs of the improvement project, usually in labor. At a cost of about US$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. NGOs conducted community meetings at which user committees comprised of local residents were selected and placed in charge of maintaining the protected springs. These committees were responsible for performing basic maintenance, including patching concrete and clearing drainage ditches, at an average cost of US$35 per year via community contributions.

    Household characteristics such as income, education and health were approximately equal among the two groups at the start of the program, suggesting that there were no systematic differences between communities that had their springs protected and those that didn’t. Throughout the program, statistics were collected on the level of water contamination and diarrheal disease in all communities and by examining changes in these measures, impacts of the intervention could be assessed.

     
    Results and Policy Lessons: 

    Impact on Diarrhea: The simple infrastructure investment of “spring cleaning” significantly reduced both water contamination and the incidence of diarrhea. There was 66 percent less E-coli contamination in treated springs than in untreated ones, and an average of 24 percent less contamination in users’ home water supplies among households who collected water from multiple springs and those who only used protected springs. This incomplete transfer of benefits may be due to the fact that households may transport and store water in contaminated vessels.

    Despite these mitigating factors, diarrheal incidence in children under 3 years old fell by 4.7 percentage points, or 25 percent, though there was no significant effect on children ages 5 to 12. Interestingly, diarrhea reduction was disproportionately concentrated among girls, suggesting that spring cleaning could be an effective tool for the improvement of female child survival.

    Behavior Modification: Possibly due to the apparent benefits of using protected springs, families began increasing their use of protected springs for drinking water, relative to other sources. However there were no significant changes in water transportation, home water chlorination, boiling or hygiene practices, implying the experience with significantly cleaned water did not increase people’s taste for water improvement.

    Willingness to Pay: Researchers used the information gathered about changes in use of protected springs to estimate how much time households were willing to expend to get cleaner water, and by extension how much they were willing to pay for it. These empirical estimates were approximately one third of what households report they are willing to pay for clean water and less than one-tenth of the value that policymakers often use when assessing social programs. The travel habits of residents of Busia, Kenya suggest that they are willing to spend at most 10.1 work days, or about US$0.89 to avert a diarrhea case. Using a high estimate for the value of time, this suggests a valuation of US$2,715 per averted child diarrhea death, far below the estimated value of a statistical life, and the cost-effectiveness cutoffs usually used in analyses of health projects in less developed countries. This implies that people either do not understand the causal link between clean water and diarrhea, which anecdotal evidence suggests they do, or that they place a lower value on improving infant and child health than typically assumed.

     

    1 Disease Control- Priorities Project, “Public Health Significance of Diarrheal Illnesses,” http://www.dcp2.org/pubs/DCP/19/Section/2531. 

    2 Parashar, Umesh, et al. “Global Illness and Deaths Caused by Rotavirus Disease in Children,” Emerging Infectious Diseases. Vol. 9. May, 2003.

     

    The Illusion of Sustainability: Comparing Free Provision of Deworming Drugs and Other "Sustainable" Approaches in Kenya

    Policy Issue: 

    Intestinal helminths—including hookworm, roundworm, schistosomiasis and whipworm—infect more than one in three people worldwide and  at least 800 million of these are school-age children. Worms are believed to have a negative impact on child development, and can contribute to lower educational attainment and income later in life. Intestinal worms can be effectively treated with low-cost drugs, but treatment must be continued indefinitely to prevent re-infection. Finding sustainable approaches to providing deworming drugs is a pressing research question, as most deworming interventions are currently financed by external institutions. Practices such as health education or cost-sharing may be able to increase program sustainability, but there is little systematic evidence on this matter.

    Context of the Evaluation: 

    Busia district is a poor and densely-settled farming region in western Kenya adjacent to Lake Victoria. This area has some of the country’s highest helminth infection rates; upwards of 90 percent of children aged 6-18 are infected. 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 several years. All schools with helminth prevalence over 50 percent were treated periodically with albendazole, as well as with praziquantel if the local prevalence of schistosomiasis was high enough.

    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 per family basis of the fee 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. 

    Social Learning: 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 percent 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 positive 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 was 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 high proportion of deworming benefits flows not to the treated child or her family, but to others in the local community through positive externalities; the lower take-up among those with more deworming knowledge may reflect their understanding of this fact. 

    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 that are reinforced through social networks.

    Balwadi deworming in India

    Policy Issue: 

    Nearly 40% of children in Africa and Asia suffer from iron deficiency anemia (IDA), which can result in weakness, stunted physical growth, and a compromised immune system. Intestinal helminths (worms) cause chronic intestinal blood loss which contributes to iron deficiency anemia. Worms are prevalent among children in developing countries and are believed to have a negative impact on education, impacting child cognitive and physical development as well as school attendance. Estimates suggest that the impact of iron deficiency anemia—through both physical and cognitive channels—could be as large as 4% of GDP on average in less developed countries, yet there is little rigorous work by economists on the effects of anemia on economic development.

    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.

    A household survey was administered to a random 30 percent of the child population from each preschool both at the baseline and then again before the final group was phased into the program. Hemoglobin (Hb) tests (to measure anemia) and parasitological tests (to measure the presence of worms) were administered in conjunction with the household survey. Child height and weight were measured during each health camp, and participation data was collected during monthly, unannounced visits to each preschool.

    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.

    Weight gains and school-participation improvements were most pronounced for sub-groups with high baseline anemia rates, in particular, for girls and children in low socioeconomic status areas.

    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.

    Edward Miguel

    Can Higher Prices Stimulate Product Use? Evidence from a Randomized Experiment in Zambia

    Policy Issue: 

    More than 1 billion people living in low-income countries do not have access to clean drinking water,1 leaving them at risk for diarrheal diseases which are transmitted when a water supply is contaminated with fecal matter. Diarrhea remains a serious concern in low-income countries, where it caused 2.6 million deaths per year between 1990 and 2000.2 Even when diarrheal episodes do not prove fatal, they can have long-term consequences on a child’s cognitive and physical development. Multiple interventions from handwashing to water source protection have been considered, but questions remain. Particularly, it is not known whether people will be more likely to use a product if it is given for free, or if the consumer is charged a small positive price.

    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

     

    Nava Ashraf, Jim Berry

    Incentivizing Safe Sex in Rural Tanzania

    Researchers examined whether making cash payments conditional on testing negative for sexually transmitted infections (STIs) can improve safe sex practices among 18-30 year olds. Results reveal that giving cash payments of US$20, conditional on testing negative for sexually transmitted diseases, significantly reduced STI infection rates among young adults in Tanzania.

    Policy Issue:

    In 2009, approximately 2.8 million people were newly infected with HIV/AIDS, but it is estimated that only 40 percent of this population is receiving treatment. The extraordinarily high social and economic costs of the current HIV and AIDS crisis suggest that prevention may be far cheaper than treatment. However, existing prevention strategies, such as large-scale behavior change interventions, have had a limited impact on the HIV/AIDS infection rate. Conditional cash transfers (CCTs) have been used in a variety of settings as a means of incentivizing socially desirable behavioral change such as school enrollment or attending at preventive healthcare check-ups. Can CCTs be used to prevent people from engaging in unsafe sex?

    Context of the Evaluation:

    While the rate of HIV new infection has decreased substantially over the past decade, HIV/AIDS is still a major problem, particularly in sub-Saharan Africa, which bears an inordinate share of the global HIV burden. In Tanzania, where new incidences of HIV have declined over the past five years, 5.6 percent of the population is still infected with HIV/AIDS. Tanzania’s neighbors to the south have fared far worse - Angola, Botswana, Lesotho, Malawi, Mozambique, Namibia, South Africa, Swaziland, Zambia, and Zimbabwe are home to 34 percent of the global population living with HIV, and experienced 31 percent of all new HIV infections in 2009.[i] Effective policies to encourage preventive behavior are desperately needed in this area.

    Description of the Intervention:

    Researchers examined whether making cash payments conditional on testing negative for sexually transmitted infections (STIs) can improve safe sex practices among 18-30 year olds.

    In the spring of 2009, 2409 individuals were randomly selected from the Ifakara Health and Demographic Surveillance System sample and then assigned to either a treatment group, where they would receive a periodic cash grant if they tested negative for STIs, or a comparison group. Participants in the treatment group were then randomly allocated into one of two sub-treatments: low-value vs. high-value CCTs. In the end, 1,124 participants were assigned to the comparison group; 660 were assigned to receive the low-value CCT of approximately US$10 per testing round; and 615 were assigned to receive the high-value CCT of US$20 per testing round.

    All participants were tested for STIs at baseline and then every 4 months for one year. Participants in the two treatment arms were eligible to receive the cash transfer payment at each testing round if they tested negative for a set of curable STIs. The STIs tested were chlamydia, gonorrhea, trichomonas, and M. genitalium; all of these diseases are transmitted through unprotected sexual contact and therefore served as a proxy for risky sexual behavior and vulnerability to HIV infection. HIV testing was conducted at baseline and at month 12, but payments were not conditioned on those results because of local sensitivities.

    Individuals in the treatment arms who tested positive for any of the curable STIs did not receive the conditional cash transfer but were eligible to continue in subsequent rounds after having been treated and cured of the infection. Anyone who tested positive for a STI, in either the comparison or treatment groups, was offered counseling and free STI treatment through health facilities of the district Ministry of Health.

    Results and Policy Lessons:

    After four and eight months in the program, there was no significant difference in the STI infection rate between either of the treatment groups and the comparison group. However, by month twelve, the high-value cash transfer led to a significant reduction in STI infection. Between month four and month twelve, the number of people testing positive for STI in the high-value conditional cash transfer arm decreased by 19 percent. In contrast, during the same time period, the number of STI-positive individuals increased by 19 percent in the low-value conditional cash transfer arm and by 13 percent in the comparison group.

    The absence of significant impacts after four and eight months suggests that the impact of the conditional cash transfer may take time to materialize, perhaps because it is not easy to extricate oneself from complicated sexual relationships, or perhaps because participants needed time to become accustomed to (and trust) the incentive mechanism.



    [i] UNAIDS (2010) “UNAIDS Report on the Global AIDS Epidemic.”

    What Matters (and What Does Not) in Malaria Prevention in Kenya

    Insecticide-treated bed nets have been proven highly effective in preventing malaria, reducing maternal anemia, and infant mortality, both directly for users and indirectly for non-users in their vicinity. Despite their proven impact, less than half of Kenyans sleep under a bednet. This study tested willingness to pay by households and a range of marketing effects. The demand for bed nets is very sensitive to price - an increase in price from free to $1 leads to a drop of 35 percentage points in take up. However gaining access to a free bednet increases households likelihood of buying one in later years. The marketing messages had no impact. 

    Policy Issue: 

    Over 10 million children under 5 die every year in the world. It is estimated that nearly two thirds of these deaths could be averted using existing preventative technologies, such as vaccines, insecticide-treated materials, vitamin supplementation or point-of-use chlorination of drinking water. A key policy question is how to increase availability and adoption of these technologies. In particular, what are the roles of prices, social networks and marketing in the adoption of such products? A commonly proposed way to increase adoption in the short-run is to distribute those essential health products for free or at highly subsidized prices. The rationale for some subsidization is evident for health interventions that generate positive health externalities. In addition, when the majority of the population is poor and credit-constrained, subsidies might be necessary to ensure access to the technologies.

    For products like vaccines, one-time adoption is sufficient to achieve eradication of the corresponding disease -- every child needs to be immunized only once. But other products, such as water treatment kits or anti-malarial bednets, require sustained adoption and use to generate the hoped-for health impact. A key question is whether policies aimed at achieving immediate adoption of such technologies increase or dampen their long-term use. It is often argued that free or highly subsidized distribution may generate a “dependency” effect, whereby beneficiaries anchor around the subsidized price and refuse to pay for the product once the subsidies are lifted. Furthermore, if people do not put free products to good use, incorrect information about the quality of the product might diffuse through the community. In this context, marketing messages might be important to increase adoption.

    Context of the Evaluation: 

    In Kenya, malaria is responsible for one out of every four child deaths.1 It impacts economic growth and productivity, and almost 170 million working days are lost annually due to the disease.2 Insecticide-treated bed nets (ITNs) are used to prevent malaria infection and have been proven highly effective in reducing maternal anemia and infant mortality, both directly for users and indirectly for non-users with a large enough share of net users in their vicinity. ITNs have been shown to reduce overall child mortality by 18% and reduce morbidity for the entire population. Despite their proven efficacy, less than half of Kenyans sleep under an ITN. Priced at US$5-7 per net, they are unaffordable to most families. Recently, a new generation of ITNs was invented: the long-lasting ITN (LLIN), which keeps its insecticide properties for its entire lifespan (typically 3-4 years).

    Details of the Intervention: 

    Households were given a voucher for a LLIN at a randomly assigned subsidy level, ranging from 40-100%. The final prices ranged from 0 to US$4.60 and households had three months to redeem their voucher. Twelve months after the distribution of the first LLIN voucher, households received a second LLIN voucher, redeemable at the same retailer as the first LLIN voucher received a year earlier. Unlike the first voucher however, all households faced the same price (US$2.30) for this second voucher. By comparing the take up rate of the second, uniformly-priced voucher in the second phase price groups, researchers are able to test whether being exposed to a large or full subsidy dampens or enhances willingness to pay for the same product a year later.

    This study also evaluated the effects of two interventions based on behavioral models derived from psychology: varying the framing of the perceived benefits; and having individuals verbally commit to purchase the product. At the time they received their first voucher, households were exposed to a randomly assigned marketing message. The “health framing” group emphasized the morbidity and mortality due to malaria which could be avoided by using the net. The “financial framing” group emphasized the financial gains households would realize (from averting medical costs and loss of daily income) if they could prevent malaria. A third group received no marketing message. Finally, a randomly selected half of all the households were asked to verbally commit to buy the ITN, and state who would sleep under it once they had bought it.

    Results and Policy Lessons: 

    Price Sensitivity: The demand for malaria-preventing bed nets in Western Kenya is relatively price sensitive; an increase in price from $0 to $1 leads to a drop of 35 percentage points in take up, and an increase from $1 to $2 leads to a further drop of 25 percentage points. Although the price effects are large, the price-elasticity observed here is lower than that found in other similar studies, possibly because households in this experiment had three months to redeem their voucher, and therefore time to save for it.

    Diffusion Effects: Gaining access to a free or highly subsidized LLIN in the first year increased households’ reported, as well as observed, willingness to pay for a second LLIN. This positive experience effect trickles down to others in the community: households facing a positive price were more likely to purchase the LLIN when the density of households around them who received a free or highly subsidized LLIN was greater.

    Marketing Effect: Neither of the two framing options (health or financial) had any impact at all on LLIN take up, and women to do not appear to have a different price-elasticity than men. Likewise, the verbal commitment treatment had no impact on actual investment behavior, despite a 92% initial agreement to purchase the LLIN.

    1The World Bank, “News & Broadcast: World Bank Intensifies Anti-Malaria Efforts in Africa”,http://go.worldbank.org/IWWIICOOC0. (Accessed August 26, 2009)
    2The World Bank, “Booster Program for Malaria Control in Africa – Kenya,”http://go.worldbank.org/EGMG4G6DX0. (Accessed September 14, 2009)

     

    Pascaline Dupas

    The Latrine Training Mat Project

    In many countries, sanitation facilities, such as simple pit latrines are common and are helpful for maintaining sanitation and preventing illness. However, young children often continue to defecate in the open long after they are old enough to use the latrine finding open pit latrines intimidating and challenging to use. Innovations for Poverty Action has developed a simple, affordable, and scalable tool called the Safe Squat ™ latrine training mat for use in such contexts. Our training mat promotes good sanitation practices from an early age and fosters a life-long habit of latrine use by converting the latrine floor into a child-friendly, easy-to-clean surface.  The Latrine Training Mat Project has piloted several prototypes of the mat in rural Western Kenya with promising results and is currently working to pilot the tool in new locations. 

    Policy Issue:

    The World Health Organization estimates that 1.5 million children die each year from diarrheal disease.[1] Evidence demonstrates that families using latrines are less likely to have children with diarrhea than those who dispose of feces improperly, in the trash, or in the open near the household. .[2] However, access to a latrine is not enough to ensure safe disposal of children’s feces. Young children, particularly those under the age of five, often do not use latrines even when they have consistent access to one.[3]Latrines, often simple pits in the ground, can be difficult for young children to use, discouraging proper sanitation practices.

    Evaluation Context:

    Among world regions, Sub-Saharan Africa has the highest proportion of basic sanitation use, including open pit latrines (without a slab or platform), bucket latrines, hanging latrines, pour flush latrines that are not connected to a sewage system, and open defecation. Open pit latrines without a slab or platform can be particularly intimidating and challenging for children to use.  Based on a series of in-depth interviews with mothers in rural Western Kenya, IPA found that children defecate in the open long after they might be capable of using a latrine for two main reasons.  First, the hole of a pit latrine is often wide enough to frighten a small child, if not pose a serious safety risk.  Secondly, mothers are reluctant to promote latrine use for young children, since the messes they create make the latrine unpleasant for other families to use.  Ironically, frequent cleaning of the latrine floor can exacerbate the problem, as the size of the hole grows when the floor is scrubbed and the mud erodes away.

    Description of the Intervention

    IPA has designed a latrine training mat (LTM) called the Safe Squat ™  that is a flat, square slab made of plastic or treated wood, approximately 60 cm across with a tapered hole about 13cm wide at the center. It is elevated a few centimeters from the ground on risers and temporarily fits over the existing latrine hole.  The Safe Squat ™ training mat is designed to safely promote good sanitation practices from an early age, while saving mothers valuable time that might otherwise have been spent cleaning the latrine or disposing of feces.

    IPA piloted the mat among two villages in Matungu District of Western Kenya.  Three prototypes were designed and tested among 12 households (six from each village). The prototypes were made of treated wood, temporary plastic, or permanent plastic, with the objective of determining the most acceptable material and design for the mat.  Both wooden and temporary plastic models were designed solely for children, and could be placed on and off the hole as needed. The permanent plastic mat was designed for the whole family to use, but the hole in the center of the mat was approximately 5 cm wider than the other two prototypes.  Data collected was qualitative in nature, consisting of in depth interviews and focus group discussions. This type of data collection assured a detailed and nuanced understanding of the participant’s experience with the latrine training mat. Following an in depth interview regarding her child’s defecation practices, mothers from each household received one of the three mat prototypes, and agreed to use the training mat with her child for at least one week. Researchers used the Trials of Improved Practice (TIP) methodology to assess whether the method of intervention delivery would influence the way in which the intervention was used and tested the intervention presentation in two ways.   In the first village, field officers merely explained that the mat was a sanitation tool to help young children use the latrine. In the second village, participants received the mat along with a detailed description of its main features, as well as explicit instructions on how the mat should be cleaned and stored.

    Results:

    Pilot Results:

    The mat was well received by intervention participants in the Kenya based pilot.  The mothers that participated in the pilot reported that they liked the tool, and reported that it saved valuable time otherwise spent cleaning the latrine, or disposing of feces. They also reported that their children liked and used the mats regularly, and that other household members approved of the tool as well. Although pilot households preferred the permanent plastic mats for the whole family’s convenience, the temporary plastic mat remained the most acceptable choice for children under the age of five. There were no observed differences in mat use, between the village that received messaging, as opposed to the one that did not.  Based on these promising results, the Latrine Training Mat Project plans to conduct future pilots in new countries. If future pilots are successful, the Latrine Training Mat Project hopes to test the mats as part of a larger randomized controlled trial. 

     


    [1]World Health Organization. “Diarrhoeal Disease” Fact Sheet No. 330. August 2009. Retrieved from www.who.int/mediacentre/factsheets/fs330/en/index.htmlon November 16, 2011.

    [2]Mertens, T; Jaffar, S; Fernando, M.A; Cousens, S.N.; Feachem, R.G. Excreta disposal behavior and latrine ownership in relation to the risk of childhood diarrhea in Sri Lanka. International Journal of Epidemiology. 21 (6); 1157-1164, 1992.  

     

    [3]Gil, A; Lanata, C; Kleinau, E; and Mary, P. Children's feces disposal practices

    in developing countries and interventions to prevent diarrheal diseases: a literature review.

    Environmental Health Project (EHP). 2004.

     

    Balancing Health Benefits and Risks of ACT Subsidies for Africa

    Policy Issues:

    Malaria is one of the world’s foremost public health concerns, killing close to 1 million people every year.  In many malaria-endemic regions, resistance has developed to all but one class of antimalarial drugs, called artemisinin combination therapies (ACTs). ACTs sold in the retail sector are unaffordable for the poor, and although heavy subsidies can make them accessible, the benefits of treating more people and lowering transmission rates must be balanced against the risk of overtreatment, which can hasten the development of drug resistance. A new malaria testing technology, the rapid diagnostic test (RDT), has made it possible to perform malaria testing in the retail sector, but these tests are not demanded at prevailing prices. How can policymakers tailor the prices of subsidized drugs and diagnostic tests to target those truly sick with malaria and prevent those who do not need ACTs from taking them?

    Context of the Evaluation:

    In Kenya, ACTs are now the only effective class of antimalarial drugs. The incidence of malaria in Western Kenya is very high, with nearly 70 percent of households self-reporting an episode of malaria in the month before baseline. ACTs at government health centers in Kenya are nominally free, but health centers feature long waits and limited hours, are often stocked out of medication, and the remotely-located poor often cannot afford to travel the distance to get there. Consequently, many people opt to purchase cheaper, less effective anti-malarials over-the-counter at drug shops located closer to home.

    The Affordable Medicines Facility for malaria (AMFm) is an initiative currently being considered by major international aid agencies in which ACTs would be heavily subsidized to first line buyers throughout Africa (the subsidy policy is currently being piloted in 8 countries). But such a high subsidy could lead to overtreatment.  If people who do not have malaria presumptively buy ACTs without a diagnosis, this can contribute to drug-resistance, waste subsidy money and delay appropriate treatment for the true cause of illness.  Improving diagnostic access could considerably reduce overtreatment, but there has been little research so far in this area.

    Description of Intervention:

    The intervention took place in the districts of Busia, Mumias and Samia in Western Kenya. Researchers distributed vouchers redeemable at local drug shops to all households within four kilometers of four rural market centers. The households were randomly assigned to one of three groups:

    Comparison

    Treatment

    I. No subsidy

    II. ACT Subsidy Only

    III. ACT and RDT Subsidy

    Households received a voucher to buy ACTs at the market price of 500 Ksh (about US$6.25)

    Households received a voucher for ACTs giving them either an 80 percent, 88 percent, or 92 percent subsidy.

    Households received an ACT voucher as in group II, and also received an RDT voucher with either an 85 percent or 100 percent subsidy.

    In order to find out what fraction of people buying ACTs were truly malaria positive—a proxy for how well the ACT subsidy under the AMFm would be targeted—the   researchers also selected a random subset of the households in treatment II and III to receive the offer of a “surprise” free RDT after they completed their transaction at the drug shop.

    Trained study officers were posted at each of the four participating drug shops during opening hours every day throughout the study period. When a household member came into a drug shop to redeem his or her voucher,  study officers recorded details such as medicines bought, symptoms, patient characteristics, and true malaria status in case an RDT was administered.  

    Results and Policy Lessons:

    An ACT subsidy increases access, especially for the poorest households (measured by the literacy status of the household head). Without subsidies, literate-headed households take ACTs for 37 percent of illness episodes as compared to 11 percent of episodes in illiterate-headed households. With subsidies, the coverage rates become 45 percent and 38 percent, respectively.

    A lower subsidy level improved targeting to malaria-positive individuals without compromising access to ACTs among those who need them. At the two lower subsidy levels (80 and 88 percent), households were less likely to use an ACT voucher for adults, but no less likely to use a voucher for young children, who are much more likely to actually have malaria and for whom malaria is most dangerous. As a result, targeting improved.

    At the two lower subsidy levels, about 75 percent of patients for whom care was sought at the drug shop tested positive for malaria, while at the 92 percent subsidy level only 56 percent tested positive. Households were very willing to take RDTs, even when asked to share some of the cost: when the test was available, over 80 percent of the households who sought treatment at the drug shop chose to take an RDT before deciding what medication to purchase. However, many chose to buy an ACT even if they tested negative.

    This evaluation suggests that an information or marketing campaign about the reliability of rapid diagnostic tests might help convince people to use and comply with them – but even without such a campaign, moving from the target AMFm subsidized price (92 percent of the retail cost) to an 80 percent ACT subsidy with RDTs could increase the share of ACT takers who are malaria positive at the drug shop by 24 percentage points.

    While these results suggest that a slightly lower ACT subsidy than the one proposed by the AMFm would improve targeting without compromising access, the results also make it clear that a large ACT subsidy is needed in order to increase access among the neediest. Taking some of the planned ACT subsidy money away from ACTs and putting it towards subsidizing and promoting RDTs could improve targeting and be particularly effective among adults, especially if adherence to test results can be improved.

    Providing Health Insurance Through Microfinance Networks in Rural India

    Policy Issue: 

    For struggling families living in poverty, economic shocks can be devastating. An unexpected home or equipment repair, loss of income, or ailing family member can drain money needed for food and housing. Health shocks are among the largest and least predictable forms of uncertainty that a poor family can face. In developing countries, high levels of poverty and poor health conditions have the potential to make health shocks all the more frequent and dangerous. Formal health insurance has the potential to mitigate the impact of health shocks.

    Context of the Evaluation: 

    Karnataka is one of the more economically progressive states in India, but much of the rural population still lives in poverty. Despite the burden imposed by health shocks, only 1% of households in rural India are estimated to have formal health insurance policies. There is little systematic evidence on effective distribution networks or the benefits of access to affordable health insurance.

    Launched in 1998, Swayam Krishi Sangam (SKS) Microfinance is one of the fastest growing microfinance organizations in the world, having provided over $92 million in loans to female clients in poor regions of India. Borrowers take loans for a range of income-generating activities. In 2007, SKS Microfinance piloted a mandatory health insurance policy for microfinance clients in rural Karnataka. The policy charges a $5 – $10 premium in exchange for $200 – $400 of coverage for hospitalization, maternity, or personal injury.

    Details of the Intervention: 

    This research project evaluates SKS Microfinance's pilot health insurance program. SKS identified 201 villages where it was running its microfinance program and was willing to pilot its new health insurance program. From this group, the researchers randomly selected 101 villages to receive the health insurance program in the summer of 2007. The other 100 villages serve as a comparison group.

    Using survey data from 5,500 randomly selected households in these 201 villages, the analysis will focus on three main topics. First, whether the program improved health outcomes and the ability of clients to repay loans. Second, to what extent the economic lives of the poor are affected by health shocks, with and without formal health insurance. Third, whether using microfinance as a way to distribute health insurance helps avoid adverse selection and moral hazard, which could undermine the sustainability of a health insurance system.

    Household and adult surveys, prior to the insurance rollout and two years after, will gauge changes in household and individual outcomes.  In addition, running surveys collect targeted information related to births and infrequent major health events. The running surveys provide a rare opportunity to observe households’ immediate reactions to these shocks, and compare those against households' long-term adjustments.

    Results and Policy Lessons:                                                    

    Preliminary findings from the analysis of baseline data reveal considerable unmet demand for insurance. Less than 1% of households have accident or health insurance, but they face frequent and serious health shocks.  The average health shock cost Rs. 1,900, while the average per-capita monthly expenditure was just Rs. 708.  Households often paid health expenses using a high-interest loan from moneylenders.  The data suggest that SKS households, despite being members of a microcredit organization, face considerable financial risk from health shocks. Bundling catastrophic health insurance with microfinance has promise to alleviate this risk.

    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

    Kenyan Life Panel Survey

    The Kenyan Life Panel Survey (KLPS) builds on an existing longitudinal dataset of educational, health and demographic information for approximately 6800 pupils in Western Kenya collected from 1998-2003, and extends it for another 6 years. In particular KLPS seeks to examine the long-run impact of a recent school-based health program - the Primary School Deworming Project - which provided free treatment for intestinal helminthes (worms) to pupils in 75 rural primary schools phased in over 5 years.  The project found that deworming had significant health and nutritional impacts, as well as leading to dramatic gains in school attendance and enrollment. After five years, educational attainment was significantly higher among early treatment school children. Evidence from KLPS linking child health gains (from deworming) and adult human capital formation could be used to justify increased investment in child health and nutrition programs.

    The KLPS tracks individuals throughout Kenya using a rigorous two stage tracking system. During the first round of household survey data collection, IPA made direct contact with nearly 85% of target individuals. Round 2 survey data collection is currently underway.

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