We use a randomized experiment in Kenya to study the impact of unconditional cash transfers on intimate partner violence. Transfers to women of on average USD 709 led to a 0.26 standard deviation (SD) decrease in physical violence, and transfers to men to a 0.18 SD decrease. Sexual violence was reduced after transfers to women (0.22 SD), but not men. We construct a theory which together with our empirical findings suggests that husbands use violence to extract resources, but dislike it otherwise. We observe large and significant spillovers: nonrecipient women in treatment villages report a 0.16 SD reduction in physical violence.
Background Novartis Access is a Novartis programme that offers a portfolio of non-communicable disease medicines at a wholesale price of US$1 per treatment per month in low-income and middle-income countries. We evaluated the effect of Novartis Access in Kenya, the first country to receive the programme. Methods We did a cluster-randomised controlled trial in eight counties in Kenya. Counties (clusters) were randomly assigned to the intervention or the control group with a covariate-constrained randomisation procedure that maximised balance on a set of demographic and health variables. In intervention counties, public and non-profit health facilities were allowed to purchase Novartis Access medicines from the Mission for Essential Drugs and Supplies (MEDS). Data were collected from all facilities served by MEDS and a sample of households in study counties. Households were eligible if they had at least one adult patient who had been diagnosed and prescribed medicines for one of the non-communicable diseases targeted by the programme: hypertension, heart failure, dyslipidaemia, type 2 diabetes, asthma, or breast cancer. Primary outcomes were availability and price of portfolio medicines at health facilities, irrespective of brand; and availability of medicines at patient households. Impacts were estimated with intention-to-treat analysis. This trial is registered with ClinicalTrials.gov (NCT02773095).
Findings On March 8, 2016, we randomly assigned eight clusters to intervention (four clusters; 74 health facilities; 342 patients) or control (four clusters; 63 health facilities; 297 patients). 69 intervention and 58 control health facilities, and 306 intervention and 265 control patients were evaluated after a 15 month intervention period (last visit February 28, 2018). Novartis Access significantly increased the availability of amlodipine (adjusted odds ratio [aOR] 2·84, 95% CI 1·10 to 7·37; p=0·031) and metformin (aOR 4·78, 95% CI 1·44 to 15·86; p=0·011) at health facilities, but did not affect the availability of portfolio medicines overall (adjusted β [aβ] 0·05, 95% CI –0·01 to 0·10; p=0·096) or their price (aβ 0·48, 95% CI –1·12 to 0·72; p=0·500). The programme did not affect medicine availability at patient households (aOR 0·83, 95% CI 0·44 to 1·57; p=0·569).
Interpretation Novartis Access had little effect in its first year in Kenya. Access programmes operate within complex health systems and reducing the wholesale price of medicines might not always or immediately translate to improved patient access. The evidence generated by this study will inform Novartis’s efforts to improve their programme going forward. The study also contributes to the public evidence base on strategies for improving access to medicines globally
We embed a field experiment in a nationwide recruitment drive for nurses in Zambia to test whether career benefits attract talent at the expense of prosocial motivation. We randomize the offer of career benefits at the recruitment stage. In line with common wisdom, treatment attracts less prosocial applicants. However, the trade-off only exists at low levels of talent; the marginal applicants in treatment are more talented and equally pro-social. These are hired, and they perform better at every step of the chain: they deliver more services, promote institutional childbirth, and reduce child malnutrition by 25% in the communities they serve.
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 (Bjorkman 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.
In Uganda, researchers conducted a large-scale randomized evaluation of a program called Accountability Can Transform (ACT) Health. The program provided community members and health care workers information about the quality of their local health services and brought them together to create action plans for how to improve local health service accountability, delivery, and quality. The study built on previous research of a similar program called Power to the People, which was found to greatly improve child health.
Twenty months after the program began:1
- The program marginally improved the quality of treatment patients received and increased patient satisfaction.
- However, the program did not affect how often people sought health care (utilization rates) or improve health outcomes; child mortality rates were unchanged.
- Results were similar one and two years into the program and were consistent across different groups; no health effects were found in any subgroup.
- Contrary to the theory of change motivating the intervention, there was no evidence that the program caused citizens to more closely monitor or apply pressure on service providers.
- Overall, the findings suggest a combination of information provision and increased oversight can marginally change the behavior of frontline service providers, but cast doubt on the power of information to foster community monitoring or to generate improvements in health outcomes, including child mortality, at least in the short term.
1 On average the time between the launch of the program and the final survey was 20 months.
Individuals care about how they are perceived by others, and take visible actions to signal their type. This paper investigates social signaling in the context of childhood immunization in Sierra Leone. Despite high initial vaccine take-up, many parents do not complete the five immunizations that are required in a child’s first year of life. I introduce a durable signal - in the form of differently colored bracelets - which children receive upon vaccination, and implement a 22-month-long experiment in 120 public clinics. Informed by theory, the experimental design separately identifies social signaling from leading alternative mechanisms. In a first main finding, I show that individuals use signals to learn about others’ actions. Second, I find that the impact of signals varies significantly with the social desirability of the action. In particular, the signal has a weak effect when linked to a vaccine with low perceived benefits and a large, positive effect when linked to a vaccine with high perceived benefits. Of substantive policy importance, signals increase timely and complete vaccination at a cost of 1 USD per child, with effects persisting 12 months after the roll out. Finally, I structurally estimate a dynamic discrete-choice model to quantify the value of social signaling.
Background: Helminth and protozoan infections affect >1 billion children globally. Improved water, sanitation, handwashing, and nutrition could be more sustainable control strategies for parasite infections than mass drug administration (MDA), while providing other quality of life benefits. Methods and Findings: We enrolled geographic clusters of pregnant women into a cluster-randomized controlled trial that tested six interventions: disinfecting drinking water(W), improved sanitation(S), handwashing with soap(H), combined WSH, improved nutrition(N), and combined WSHN. We assessed intervention effects on parasite infections by measuring Ascaris lumbricoides, Trichuris trichiura, hookworm, and Giardia duodenalis among individual children born to enrolled mothers and their older siblings (ClinicalTrials.gov NCT01704105). We collected stool specimens from 9077 total children in 622 clusters, including 2346 children in control, 1117 in water, 1160 in sanitation, 1141 in handwashing, 1064 in WSH, 1072 in nutrition, and 1177 in WSHN. In the control group, 23% of children were infected with Ascaris lumbricoides, 1% with Trichuris trichuria, 2% with hookworm and 39% with Giardia duodenalis. After two years of intervention exposure, Ascaris infection prevalence was 18% lower in the water treatment arm (95% confidence interval (CI) 0%, 33%), 22% lower in the WSH arm (CI 4%, 37%), and 22% lower in the WSHN arm (CI 4%, 36%) compared to control. Individual sanitation, handwashing, and nutrition did not significantly reduce Ascaris infection on their own, and integrating nutrition with WSH did not provide additional benefit. Trichuris and hookworm were rarely detected, resulting in imprecise effect estimates. No intervention reduced Giardia. Reanalysis of stool samples by quantitative polymerase chain reaction (qPCR) confirmed the reductions in Ascaris infections measured by microscopy in the WSH and WSHN groups. Lab technicians and data analysts were blinded to treatment assignment, but participants and sample collectors were not blinded. The trial was funded by the Bill & Melinda Gates Foundation and USAID. Conclusions: Our results suggest integration of improved water quality, sanitation, and handwashing could contribute to sustainable control strategies for Ascaris infections, particularly in similar settings with recent or ongoing deworming programs. Water treatment alone was similarly effective to integrated WSH, providing new evidence that drinking water should be given increased attention as a transmission pathway for Ascaris. Clinical trial registration ID #NCT01704105.
In Rwanda, we have continued our global tradition of rigorous, applicable research by building foundational research capacity and conducting evaluations in areas of pressing national concern. Examples of our work below offer promising insights into everyday issues that affect the lives of the Rwandan poor.
How do standard development programs compare to just giving people cash? In Rwanda, researchers conducted a randomized evaluation to shed light on this question. Villages were randomly assigned to one of four groups: they received either a USAID-funded, integrated WASH and nutrition program (with savings and asset transfer components), unconditional cash grants of equal cost to the donor, a larger cash transfer, or no program at the time of study. The transfers were funded by USAID and Google.org.
The evaluation measured impacts on five main health and economic outcomes: household dietary diversity, maternal and child anemia, child growth (height-for-age, weight-for-age, and mid-upper arm circumference), household wealth, and household consumption, as well as other secondary outcomes, such as savings.
After approximately one year:
» The integrated nutrition and WASH program had a positive impact on savings, a secondary outcome, among the eligible population, but did not impact any primary outcomes (household dietary diversity, maternal or child anemia, child growth, household consumption, or wealth) within the period of the study.
» An equivalent amount of cash (a cost to USAID of $142 per household) allowed households to pay down debt and boosted productive and consumption assets, but did not impact child health outcomes.
» A much larger cash transfer—of more than $500 per household—had a wide range of benefits: it not only increased consumption, savings, assets, and house values,but improved household dietary diversity and height-for-age, and decreased child mortality.
» The results suggest that, over the time period of the study, targeted programs focused on changing specific outcomes may be able to do so at lower cost than cash, but that large investments of cash can more rapidly affect some leading indicators of malnutrition.
» The results also suggest that large cash transfers impact not only the economic measures of consumption and wealth, but also dietary diversity, height-for-age, and child mortality, while small transfers appear to have more limited benefits.
Maternal mortality remains very high in many parts of the developing world, especially in sub-Saharan Africa. Limited awareness of risk factors for maternal mortality such as maternal age and birth spacing may contribute to persistently high death rates, and public health campaigns to increase awareness of risk factors could help curb maternal mortality. Research shows that men, in particular, tend to underestimate maternal mortality risk, which may lead to their lower demand for contraception. Researchers worked in close collaboration with Zambia’s Ministry of Health and local NGOs to evaluate the impact of providing information to men and women about maternal mortality risk on knowledge of risk, demand for family planning, and maternal and child health outcomes. Preliminary results indicate that providing husbands with the information led to a reduction in fertility in the year that followed, while providing information to women had no comparable impact.
Although abortion is now legal in Kenya under expanded circumstances, access is limited and many providers and individuals still believe it is illegal. This study aimed to characterise Kenyan women’s perceptions and experiences with abortion and post-abortion care (PAC) services in Nairobi regarding barriers to care, beliefs about abortion, and perceived stigma. We conducted 15 semi-structured in-depth interviews with Kenyan women aged 18–24 years who recently received abortion and PAC services at four Marie Stopes Kenya clinic sites in Nairobi. The most significant psychosocial barrier respondents faced in promptly seeking abortion and PAC was perceived stigma. In response to stigma, participants developed a sense of agency and self-reliance, which allowed them to prioritise their own healthcare needs over the concerns of others. To adequately address perceived stigma as a barrier to abortion- and PAC-seeking, significant cultural norm shifting is required.
- Simple growth charts, which allowed parents to see if their child had a normal height for their age, did not reduce reduce growth deficits on average among the 547 children in the study, but among malnourished children, reduced stunting by 22 percentage points.
- In contrast, inviting caregivers to quarterly meetings to learn if their children had a normal height and weight and providing food supplements to malnourished children had no impact on rates of stunting.
- Neither home-based growth charts nor community-based monitoring were found to impact children’s cognitive development.
- Home-based growth charts appear to be a cost-effective tool to reduce physical growth deficits in this context. For every dollar that was invested in growth charts, children who otherwise would have been stunted gained an estimated $16 in additional lifetime wages.
We present the results of a study designed to ‘benchmark’ a major USAID-funded child malnutrition program against what would have occurred if the cost of the program had simply been disbursed directly to beneficiaries to spend as they see fit. Using a three-armed trial from 248 villages in Rwanda, the study measures impacts on households containing poor or underweight children, or pregnant or lactating women, as well as the broader population of study villages. We find that the bundled health program delivers benefits in an outcome directly targeted by specific sub-components of the intervention (savings), but does not improve household dietary diversity, child anthropometrics, or anemia within the year of the study. A cost-equivalent cash transfer boosts productive asset investment and allows households to pay down debt. The bundled program is significantly better in cost-equivalent terms at generating savings and worse for debt reduction, while cost-equivalent cash drives more asset investment. A much larger cash transfer of more than $500 per household improves a wide range of consumption measures including dietary diversity, as well as savings, assets, and housing values. Only the large cash transfer shows evidence of moving child outcomes, with significant but modest improvements in child height-for-age, weight-for-age, and mid upper-arm circumference (about 0.1 SD). The results indicate that programs targeted towards driving specific outcomes can do so at lower cost than cash, but large cash transfers drive substantial benefits across a wide range of impacts, including many of those targeted by the more tailored program.