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Participatory development is designed to mitigate problems of political bias in pre-existing local government but also interacts with it in complex ways. Using a five-year randomized controlled study in 97 clusters of villages (194 villages) in Ghana, we analyze the effects of a major participatory development program on participation in, leadership of and investment by pre-existing political institutions, and on households’ overall socioeconomic well-being. Applying theoretical insights on political participation and redistributive politics, we consider the possibility of both cross-institutional mobilization and displacement, and heterogeneous effects by partisanship. We find the government and its political supporters acted with high expectations for the participatory approach: treatment led to increased participation in local governance and reallocation of resources. But the results did not meet expectations, resulting in a worsening of socioeconomic wellbeing in treatment versus control villages for government supporters. This demonstrates international aid’s complex distributional consequences. 

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Working Paper
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March 24, 2020
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Developing countries are characterized by high rates of mortality and morbidity. A potential contributing factor is the low utilization of health systems, stemming from the low perceived quality of care delivered by health personnel. This factor may be especially critical during crises, when individuals choose whether to cooperate with response efforts and frontline health personnel. We experimentally examine efforts aimed at improving health worker performance in the context of the 2014–15 West African Ebola crisis. Roughly two years before the outbreak in Sierra Leone, we randomly assigned two social accountability interventions to government-run health clinics — one focused on community monitoring and the other gave status awards to clinic staff. We find that over the medium run, prior to the Ebola crisis, both interventions led to improvements in utilization of clinics and patient satisfaction. In addition, child health outcomes improved substantially in the catchment areas of community monitoring clinics. During the crisis, the interventions also led to higher reported Ebola cases, as well as lower mortality from Ebola — particularly in areas with community monitoring clinics. We explore three potential mechanisms: the interventions (1) increased the likelihood that patients reported Ebola symptoms and sought care; (2) unintentionally increased Ebola incidence; or (3) improved surveillance efforts. We find evidence consistent with the first: by improving the perceived quality of care provided by clinics prior to the outbreak, the interventions likely encouraged patients to report and receive treatment. Our results suggest that social accountability interventions not only have the power to improve health systems during normal times, but can additionally make health systems resilient to crises that may emerge over the longer run.

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Working Paper
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March 06, 2020
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Globally, access to good quality abortion services and post-abortion care is a critical determinant for women’s survival after unsafe abortion. Unsafe abortions account for high levels of maternal death in Kenya. We explored women’s experiences and perceptions of their abortion and post-abortion care experiences in Kenya through person-centred care. This qualitative study included focus group discussions and in-depth interviews with women aged 18-35 who received safe abortion services at private clinics. Through thematic analyses of women’s testimonies, we identified gaps in the abortion care and person-centred domains which seemed to be important throughout the abortion process. When women received clear communication and personalised comprehensive information on abortion and post-abortion care from their healthcare providers, they reported more positive experiences overall and higher reproductive autonomy. Communication and supportive care were particularly valued during the post-abortion period, as was social support more generally. Further research is needed to design, implement and test the feasibility and acceptability of person-centred abortion care interventions in community and clinical settings with the goal of improving women’s abortion experiences and overall reproductive health outcomes.

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Published Paper
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February 27, 2020
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Context: A growing body of evidence indicates that nonclinical health care facility staff provide support beyond their traditional roles, particularly in low- and middle-income countries. It is important to examine the role of health facility cleaners in Kenya—from their perspective—to better understand their actual and perceived responsibilities in maternity care.

Methods: In-depth, face-to-face interviews using a semistructured guide were conducted with 14 cleaners working at three public health facilities in Nairobi and Kiambu Counties, Kenya, in August and September 2016. Results were coded and categorized using a thematic content analysis approach.

Results: Cleaners reported performing a range of services beyond typical maintenance responsibilities, including providing emotional, informational and instrumental support to maternity patients. They described feeling disrespected when patients were untidy or experienced bleeding; however, such examples revealed cleaners' need to better understand labor and childbirth processes. Cleaners also indicated a desire for training on interpersonal skills to improve their interactions with patients.

Conclusion: Cleaners' direct involvement in maternity patients' care is an alarming symptom of overburdened health facilities, insufficient staffing and inadequate training. This key yet overlooked cadre of health care staff deserves appropriate support and further research to understand and alleviate health system shortcomings, and to improve the quality of maternity health care provision.

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Published Paper
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February 12, 2020

¿Pueden los cursos de educación sexual en línea mejorar el conocimiento, las actitudes y el comportamiento de los estudiantes en materia de salud sexual? ¿Estos cursos también tienen efectos positivos en los compañeros de los estudiantes que toman el curso? Los investigadores evaluaron el impacto de un curso de educación sexual en línea sobre el conocimiento y el comportamiento sexual de los estudiantes de escuelas secundarias urbanas colombianas. El programa de educación tuvo un impacto significativo en conocimiento y actitudes. No se encontraron impactos en las medidas de comportamiento auto informadas, pero el programa condujo a una reducción en la incidencia de enfermedades de transmisión sexual entre las mujeres sexualmente activas. Además, los resultados mostraron un aumento significativo en la redención de cupones para condones entre los estudiantes del grupo de tratamiento.

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February 12, 2020
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Little evidence exists on women’s experiences of care during abortion care, partly due to limitations in existing measures. Moreover, globally, the development and rapid growth in the availability of medication abortions (MA) has radically changed the options for safe abortions for women. It is therefore important to understand how women’s experiences of care may differ across medication and manual vacuum aspiration (MVA) abortions. This study uses a validated person-centered abortion care scale (categorized as low, medium, and high levels, with high levels representing the greatest level of person-centered care) to assess women’s experiences of care undergoing medication abortions vs. MVA. This paper reports on a cross-sectional study of 353 women undergoing abortions at one of six family planning clinics in Nairobi County, Kenya in 2018. Comparing abortion types, we found that the MVA sample was more likely to report “high” levels of person-centered abortion care compared to the MA sample (36.3% vs. 23.0%, p = 0.005). No differences were detected with respect to Respectful and Supportive Care; however, the MVA sample was significantly more likely to report “high” levels of Communication and Autonomy compared to the MA sample (23.6% vs. 11.2%, p<0.0001). In multivariable ordered logistic regression, we found that the MVA sample had a 92% greater likelihood of reporting higher person-centered abortion care scores compared to MA clients (aOR1.92, CI: 1.17–3.17). Being employed and reporting higher self-rated health were associated with higher person-centered abortion care scores, while reporting higher levels of stigma were associated with lower person-centered abortion care scores. Our findings suggest that more efforts are needed to improve the domain of Communication and Autonomy, particularly for MA clients.

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Published Paper
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November 25, 2019
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Globally, violence against women is a leading cause of premature death and morbidity for women and almost one-third of women report experiencing intimate partner violence (IPV) or sexual violence by a non-partner at some point in their life. Yet rigorous evidence on scalable and effective ways to reduce IPV is limited, in part because measuring IPV is challenging. Current standards of practice for reducing gender-based violence are also relatively limited in scope, focusing mainly on changing gender norms. Designing and testing new approaches has the potential to yield more effective solutions. IPA’s Intimate Partner Violence Initiative, a partnership with the International Rescue Committee, exists to address these challenges. The initiative designs and tests innovative solutions to IPV, leverages existing research to identify factors that contribute to IPV and works to address methodological and measurement challenges in violence research and related fields. With our academic and implementing partners, IPA has identified a number of effective solutions, including mass media campaigns, coupling women’s economic empowerment with gender dialogue, and teaching secondary school students soft skills. Results from several initiative-supported studies are forthcoming. Further research will be needed to validate results in new contexts and at scale, and to design and evaluate new ideas.

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Brief
Date:
October 22, 2019
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Objective: Despite the recognized importance of person-centered care, very little information exists on how person-centered maternity care (PCMC) impacts newborn health.

Methods: Baseline and follow-up data were collected from women who delivered in government health facilities in Nairobi and Kiambu counties in Kenya between August 2016 and February 2017. The final analytic sample included 413 respondents who completed the baseline survey and at least one follow-up survey at 2, 6, 8, and/or 10 weeks. Data were analyzed using descriptive, bivariate, and multivariate statistics. Logistic regression was used to assess the relationship between PCMC scores and outcomes of interest.

Results: In multivariate analyses, women with high PCMC scores were significantly less likely to report newborn complications than women with low PCMC scores (adjusted odds ratio [aOR] 0.39, 95% confidence interval [CI] 0.16–0.98). Women reporting high PCMC scores also had significantly higher odds of reporting a willingness to return to the facility for their next delivery than women with low PCMC score (aOR 12.72, 95% CI 2.26–71.63). The domains of Respect/Dignity and Supportive Care were associated with fewer newborn complications and willingness to return to a facility.

Conclusion: PCMC could improve not just the experience of the mother during childbirth, but also the health of her newborn and future health-seeking behavior.

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September 20, 2019
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Objectives: This study aimed to assess the accuracy of pregnant women’s perceptions of maternity facility quality and the association between perception accuracy and the quality of facility chosen for delivery.

Design: A cohort study.

Setting: Nairobi, Kenya.

Participants: 180 women, surveyed during pregnancy and 2 to 4 weeks after delivery.

Primary outcome measures: Women were surveyed during pregnancy regarding their perceptions of the quality of all facilities they were considering during delivery and then, after delivery, about their ultimate facility choice. Perceptions of quality were based on perceived ability to handle emergencies and complications. Delivery facilities were assigned a quality index score based on a direct assessment of performance of emergency ‘signal functions’, skilled provider availability, medical equipment and drug stocks. ‘Accurate perceptions’ was a binary variable equal to one if a woman’s ranking of facilities based on her quality perception equalled the index ranking. Ordinary least squares and logistic regressions were used to analyse associations between accurate perceptions and quality of the facility chosen for delivery.

Results: Assessed technical quality was modest, with an average index score of 0.65. 44% of women had accurate perceptions of quality ranking. Accurate perceptions were associated with a 0.069 higher delivery facility quality score (p=0.039; 95%CI: 0.004 to 0.135) and with a 14.5% point higher probability of delivering in a facility in the top quartile of the quality index (p=0.015; 95%CI: 0.029 to 0.260).

Conclusions: Patient misperceptions of technical quality were associated with use of lower quality facilities. Larger studies could determine whether improving patient information about relative facility quality can encourage use of higher quality care.

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Published Paper
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July 30, 2019
English

Innovations for Poverty Action (IPA) is a research and policy non-profit that discovers and promotes effective solutions to global poverty problems. IPA brings together researchers and decision-makers to design, rigorously evaluate, and refine these solutions and their applications, ensuring that the evidence created is used to improve the lives of the world’s poor. Since our founding in 2002, IPA has worked with over 575 leading academics to conduct over 650 evaluations in 51 countries. Future growth will be concentrated in focus countries, such as Myanmar, where we have local and international staff, established relationships with government, NGOs, and the private sector, and deep knowledge of local issues.

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Brief
Date:
July 08, 2019
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Background

Globally, there has been increasing attention to women’s experiences of care and calls for a person-centered care approach. At the heart of this approach is the patient-provider relationship. It is necessary to examine the extent to which providers and women agree on the care that is provided and received. Studies have found that incongruence between women’s and providers’ perceptions may negatively impact women’s compliance, satisfaction, and future use of health facilities. However, there are no studies that examine patient and provider perspectives on person-centered care.

Methods

To fill this gap in the literature, we use cross-sectional data of 531 women and 33 providers in seven government health facilities in Kenya to assess concordance and discordance in person-centered care measures. Additionally, we analyze 41 in-depth interviews with providers from three of these facilities to examine why differences in reporting may occur. Descriptive statistical methods were used to measure the magnitude of differences between reports of women and reports of providers. Thematic analyses were conducted for provider surveys.

Results

Our findings suggest high discordance between women and providers’ perspectives in regard to person-centered care experiences. On average, women reported lower levels of person-centered care compared to providers, including low respectful and dignified care, communication and autonomy, and supportive care. Providers were more likely to report higher rates of poor health facility environment such as having sufficient staff. We summarize the overarching reasons for the divergence in women and provider reports as: 1) different understanding or interpretation of person-centered care behaviors, and 2) different expectations, norms or values of provider behaviors. Providers rationalized abuse towards women, did not allow a companion of choice, and blamed women for poor patient-provider communication. Women lacked assurance in privacy and confidentiality, and faced challenges related to the health facility environment. Providers attributed poor person-centered care to both individual and facility/systemic factors.

Conclusions

Implications of this study suggests that providers should be trained on person-centered care approaches and women should be counseled on understanding patient rights and how to communicate with health professionals.

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June 10, 2019
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For the most vulnerable, even small negative shocks can have significant short- and long-term impacts. Few interventions that improve shock-coping are widely available in sub-Saharan Africa. Researchers test whether individual pre- cautionary savings can mitigate a shock-coping behavior with potentially neg- ative spillovers: transactional sex. Sex for money is a common shock-coping behavior in sub-Saharan Africa and is believed to be a leading driver of the HIV/AIDS epidemic. In a field experiment in Kenya, researchers randomly assigned half of 600+ participating, vulnerable women to a savings intervention that consists of opening a mobile banking savings account labeled for emergency expenses and individual goals. The intervention led to an increase in total mobile savings, reductions in transactional sex as a risk-coping response to shocks, and a decrease in symptoms of sexually transmitted infections.

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Working Paper
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June 05, 2019
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While much progress has been made in global health over the last decade, advancement has been slower on certain key indicators such as maternal mortality. Contraception and family planning can reduce the risk of maternal mortality and other health complications associated with high fertility rates, early pregnancies, and short birth spacing, but women around the world continue to report a large unmet need for contraception.

Low use of family planning and contraception is a particular concern in sub-Saharan Africa because of persistently high rates of HIV/AIDS and a highest incidence of maternal mortality. For every 100,000 live births, 547 women died in childbirth in sub-Saharan Africa in 2015, according to the World Bank.

Innovations for Poverty Action (IPA), along with academic researchers and implementing partners, conducts rigorous research on reproductive health to identify cost-effective ways to increase access to and use of family planning and reproductive health services, reduce the incidence of high-risk pregnancies, and improve the quality of services. Previous research has included testing the impact of providing information about risk to different populations, removing fees for contraception, providing families with incentives to delay the marriage of their daughters, and has investigated other critical questions.

While a body of evidence is emerging on this topic, policymakers and implementers need more evidence on cost-effective and scalable ways to improve access to and increase demand for high-quality reproductive health and family planning services.

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Brief
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May 01, 2019
English

Over 700 million people live on less than US$1.90 per day.1 Many of these families depend on insecure and fragile livelihoods. Globally nearly half of all deaths in children under 5 are attributable to undernutrition, translating into the loss of about 3 million young lives a year.2 Recent research has shown that holistic livelihoods programs, such as the Graduation Approach can have a wide range of benefits for these poor families, from increasing household consumption and income to improving food security and mental health. The Graduation model provides families with a range of services, including income-generating assets, training, access to savings accounts, consumption support, and coaching visits, and variations of the model have been successfully replicated in several contexts. The aim of this research in Burkina Faso is to rigorously evaluate whether an adapted Graduation program design, which focuses on strengthening the household’s ability to cope with crises, leads to improvements in child nutrition and household food security. The baseline survey found the program has effectively targeted nutritionally vulnerable households. The randomized evaluation is ongoing. 


[1] http://www.worldbank.org/en/news/press-release/2018/09/19/decline-of-global-extreme-poverty-continues-but-has-slowed-world-bank

[2] https://data.unicef.org/topic/nutrition/malnutrition/

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March 27, 2019

We evaluate the impact of a large-scale information and mobilization intervention designed to improve health service delivery in rural Uganda by increasing citizens’ ability to monitor and apply bottom-up pressure on underperforming health workers. Modeled closely on the landmark “Power to the People” study (Björkman and Svensson, 2009), the intervention was undertaken in 376 health centers in 16 districts and involved a three-wave panel of more than 14,000 households. We find that while the intervention had a modest positive impact on treatment quality and patient satisfaction, it had no effect on utilization rates or health outcomes (including child mortality). We also find no evidence that the channel through which the intervention affected treatment quality was citizen monitoring. The results hold in a wide set of pre-specified subgroups and also when, via a factorial design, we break down the complex intervention into its two most important components. Our findings cast doubt on the power of information to foster community monitoring or to generate improvements in health outcomes, at least in the short term.

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Working Paper
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March 26, 2019

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