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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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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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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

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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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.

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Working Paper
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February 24, 2019
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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

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February 21, 2019
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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.

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Working Paper
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February 05, 2019
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Violence against women (VAW) is widespread in East Africa, with almost half of married women experiencing physical abuse. Those seeking to address this policy issue confront two challenges. First, some forms of domestic violence are widely condoned; majorities of men and women believe that a husband is justified in beating his wife in a variety of scenarios. Second, victims and bystanders are often reluctant to report incidents to authorities. Building on a growing literature showing that education-entertainment can change norms and behaviors, we present experimental evidence from a media campaign attended by over 10,000 Ugandans in 112 villages. In randomly assigned villages, video dramatizations discouraged VAW and encouraged reporting. Results from interviews conducted several months after the intervention show no change in attitudes condoning VAW yet a substantial increase in willingness to report to authorities, especially among women, and a decline in the share of women who experienced violence.
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Working Paper
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January 31, 2019
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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.

Key Findings

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.

On average the time between the launch of the program and the final survey was 20 months.

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December 14, 2018
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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 approximately 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.

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Working Paper
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December 12, 2018
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In Zambia, 40% of children under the age of five are stunted. Addressing stunting in children requires continuous efforts by caregivers; if caregivers are unaware of their child’s growth faltering, increased attention to child nutrition in the household seems unlikely. In 2015, we conducted a cluster- randomized trial to test a pair of interventions designed to provide caregivers with information on their children’s physical growth. This report describes a qualitative follow-up study with participants of that trial. The aim of the follow-up study was to learn about parents’ perceptions of the original interventions and to understand the general views of parents on early child physical growth. The learnings generated by this follow-up study will be used to refine the design of the interventions and will also shed light on challenges in addressing child growth in Zambia more generally.

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Report
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December 04, 2018

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