IPA Zambia is pleased to share with you its final bulletin of the year: "2016 in Review." This bulletin highlights ten of IPA Zambia's research projects, including updates from projects included in the previous bulletin as well as new contributions. We hope you enjoy this look at the high-quality evidence we've generated this past year, and we look forward to continuing this work with you in the year ahead.
The “community-based development” approach may empower citizens and improve outcomes through three mechanisms: (1) an immediate direct effect of engaging citizens to decide how to allocate resources within the community-based development program, (2) an indirect effect on community organization that improves citizen engagement with other local institutions, and (3) an indirect effect on community organization that improves representation within centralized government structures. Using a randomized evaluation of a nongovernmental-organization-led CBD program in Ghana, we examine whether community-based development results in citizens’ empowerment to improve their socioeconomic well-being through these mechanisms. We find that the leadership training and experiences associated with community-based development translate into higher perceived quality of village leaders, but they simultaneously decrease contributions to collective projects outside the context of the community-based development program. In addition, although the process encourages more people to run for district-level office and results in more professional political representation, it does not increase aggregate levels of government investment in communities. Ultimately, we find that although the program led to changes in village-level and district-level leadership, it did not increase investment in public goods and did not improve socio-economic outcomes.
Despite poverty and limited access to health care, evidence is growing that patients in low-income countries are taking a more active role in their selection of health care providers. Urban areas such as Nairobi, Kenya offer a rich context for studying these “active” patients because of the large number of heterogeneous providers available. We use a unique panel dataset from 2015 in which 402 pregnant women from peri-urban (the “slums” of) Nai- robi, Kenya were interviewed three times over the course of their pregnancy and delivery, allowing us to follow women's care decisions and their perceptions of the quality of care they received. We define active antenatal care (ANC) patients as those women who switch ANC providers and explore the prevalence, characteristics and care- seeking behavior of these patients. We analyze whether active ANC patients appear to be seeking out higher qual- ity facilities and whether they are more satisfied with their care. Women in our sample visit over 150 different public and private ANC facilities. Active patients are more educated and more likely to have high risk pregnancies, but have otherwise similar characteristics to non-active patients. We find that active patients are increasingly likely to pay for private care (despite public care being free) and to receive a higher quality of care over the course of their pregnancy. We find that active patients appear more satisfied with their care over the course of pregnan- cy, as they are increasingly likely to choose to deliver at the facility providing their ANC.
Background: The recent global climate agreement in Paris aims to mitigate greenhouse gas emissions while fostering sustainable development, and establishes an international trading mechanism to meet this goal. Currently, carbon offset program implementers are allowed to collect their own monitoring data to determine the number of carbon credits to be awarded.
Objectives: We summarize reasons for mandating independent monitoring of greenhouse gas emission reduction projects. In support of our policy recommendations, we describe a case study of a program designed to earn carbon credits by distributing almost one million drinking water filters in rural Kenya to avert the use of fuel for boiling water. We compare results from an assessment conducted by our research team in the program area among households with pregnant women or caregivers in rural villages with low piped water access with the reported program monitoring data and discuss the implications.
Discussion: Our assessment in Kenya found lower household water filter usage levels than the internal program monitoring reported estimates used to determine carbon credits; we found 19% (N=4041) of households reported filter usage 2-3 years after filter distribution compared to the program stated usage rate of 81% (N=14988) 2.7 years after filter distribution. Although carbon financing could be a financially sustainable approach to scale up water treatment and improve health in low-income settings, these results suggest program effectiveness will remain uncertain in the absence of requiring monitoring data be collected by third-party organizations.
Conclusion: Independent monitoring should be a key requirement for carbon credit verification in future international carbon trading mechanisms to ensure programs achieve benefits in line with sustainable development goals.
Systematic reviews of existing evidence show promising effects of community health worker (CHW) programs as a strategy to improve child survival, but also highlight challenges faced by CHW programs, including insufficient incentives to deliver timely and appropriate services. We assessed the effect of an incentivized community health delivery program in Uganda on all-cause under-five mortality. A cluster-randomized controlled trial, embedded within the scale-up of a new community health delivery program, was undertaken in 214 clusters in 10 districts in Uganda. In the intervention clusters micro entrepreneur-based community health promoters (CHPs) were deployed over a three-year period (2011-2013). On average 38 households were surveyed in each cluster at the end of 2013, for a total sample size of 8,119 households. The primary study outcome was all-cause under-five mortality (U5MR). U5MR was reduced by 27% (adjusted RR 0.73, 95% CI 0.58-0.93).
I investigate whether a school-based deworming intervention in Kenya had long-term effects on young children in the region. I exploit positive externalities from the program to estimate impacts on younger children who were not directly treated. Ten years after the intervention, I find large cognitive effects—comparable to between 0.5 and 0.8 years of schooling—for children who were less than one year old when their communities received mass deworming treatment. I find no effect on child height or stunting. Because treatment was administered through schools, I also estimate effects among children whose older siblings received treatment directly; in this subpopulation, effects on cognition are nearly twice as large.
Women who received private access to vouchers for contraceptives were more likely to take up and use contraception, compared to women whose husbands were involved in the voucher program. In contexts in which women have less bargaining power in family planning decisions, providing private access to contraceptives may be an important and effective means of enabling women to achieve their fertility goals.
State capacity to provide public services depends on the motivation of the agents recruited to deliver them. We design an experiment to quantify the effect of agent selection on service effectiveness. The experiment, embedded in a nationwide recruitment drive for a new government health position in Zambia, shows that agents attracted to a civil service career have more skills and ambition than those attracted to “doing good”. Data from a mobile platform, administrative records, and household surveys show that they deliver more services, change health practices, and produce better health outcomes in the communities they serve.
This study estimates long-run impacts of a child health investment, exploiting community-wide experimental variation in school-based deworming. The program increased labor supply among men and education among women, with accompanying shifts in labor market specialization. Ten years after deworming treatment, men who were eligible as boys stay enrolled for more years of primary school, work 17% more hours each week, spend more time in non-agricultural self-employment, are more likely to hold manufacturing jobs, and miss one fewer meal per week. Women who were in treatment schools as girls are approximately one quarter more likely to have attended secondary school, halving the gender gap. They reallocate time from traditional agriculture into cash crops and non-agricultural self-employment. We estimate a conservative annualized financial internal rate of return to deworming of 32%, and show that mass deworming may generate more in future government revenue than it costs in subsidies.
We study how healthcare subsidies and improved information affect over- and under-use of primary healthcare in a randomized control trial of 1544 children in Mali. In a dynamic model of healthcare demand, misuse relative to policymaker preferences (here given by WHO care-seeking standards) arises from seeking care too early or too late during an illness spell. Using nine weeks of daily data, we show that the barrier to optimal care seeking is cost, not information: subsidies increase demand by over 250%, but overuse is rare with or without the subsidy. Information, contrary to intent, appears to increase underuse, as our model predicts.
In a field experiment in Uganda, we find that demand after a free distribution of three health products is lower than after a sale distribution. This contrasts with work on insecticide-treated bed nets, highlighting the importance of product characteristics in determining pricing policy. We put forward a model to illustrate the potential tension between two important factors, learning and anchoring, and then test this model with three products selected specifically for their variation in the scope for learning. We find the rank order of shifts in demand matches with the theoretical prediction, although the differences are not statistically significant.
Lack of income, inadequate health services, and poor infrastructure contribute to poor global health. With more than 100 health-related studies, IPA generates evidence on effective ways to improve access to quality health services and products, and ensure people use them.
In recent years, great progress has been made in global health. Rates of chronic hunger and child mortality are half what they were two decades ago. However, at the same time, progress has been slow in other areas, such as maternal mortality, access to improved sanitation, and the incidence of malaria. To determine how best to address these challenges and many others, IPA partners with health ministries, civil society organizations, and NGOs working in the sector to discover and encourage the use of effective approaches for improving health systems and programs. Among its findings, this research has identified cost-effective methods to reduce the incidence of diarrhea in children under five years of age, examined the role of subsidies in improving access to preventive health, and ways to recruit effective community health workers.
The new handwashing system, designed with end user input, features an economical foaming soap dispenser and a hygienic, water-efficient tap for use in household and institutional settings that lack reliable access to piped water. Cost of the soap and water needed for use is less than US$0.10 per 100 handwash uses, compared with US$0.20–$0.44 for conventional handwashing stations used in Kenya.
Using an interactive and iterative design approach involving representative end users, we created a new handwashing system in Kisumu, Kenya, to make handwashing convenient and economical in areas without reliable piped water. The innovative and adaptable system, branded as Povu Poa (“Cool Foam” in Kiswahili), integrates a cost-effective foaming soap dispenser with a hygienic, water-frugal water tap in a secure and affordable design.
In the previous IPA Health Bulletin (August 2015) we discussed the discernible positive differences in household behaviors and child health in districts where the Community Health Assistants were recruited using career incentives (“Career CHAs”) in comparison with those recruited using community incentives (“Control CHAs”). Over the past months IPA has been meeting with government stakeholders - including the MOH HR Technical Working Group - and presenting what these results mean for the cost-benefit of providing career incentives for the CHAs. Here is a brief summary of that presentation.
A seven-year randomized evaluation suggests education subsidies reduce adolescent girls’ dropout, pregnancy, and marriage but not sexually transmitted infection (STI). The government’s HIV curriculum, which stresses abstinence until marriage, does not reduce pregnancy or STI. Both programs combined reduce STI more, but cut dropout and pregnancy less, than education subsidies alone. These results are inconsistent with a model of schooling and sexual behavior in which both pregnancy and STI are determined by one factor (unprotected sex), but consistent with a two-factor model in which choices between committed and casual relationships also affect these outcomes.