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.
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.
Can improved toilet facilities, combined with innovative accountability systems for maintenance, increase the use of community toilets in urban India?
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?
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.
What is the impact and cost-effectiveness of rain-fed water cisterns as a main source of water access in rural areas lacking other water sources? This project studies a 16,000 liter cistern for residential use which is filled during the rainy season, and – in theory – should provide families enough water for cooking and drinking during the dry season.
The technology is well developed, and the Brazilian government has been providing thousands of these cisterns to a target population of millions in northeast Brazil for the last 8 years. However, a rigorous randomized control trial of the adequacy of this technology and its impacts at the household level has not been performed up to now.
We have partnered with the local NGO building the cisterns (ASA) and the Brazilian Government (MDS), and obtained their support for a randomized control trial of their program. Funding for cistern-building has been obtained from the Spanish Development Agency in Brazil and the Brazilian Government.
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.
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.
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.
The World Health Organization estimates that 1.5 million children die each year from diarrheal disease. 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. . 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.Latrines, often simple pits in the ground, can be difficult for young children to use, discouraging proper sanitation practices.
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.
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.
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.
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.