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.
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 600 leading academics to conduct over 830 evaluations in 52 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.
Innovations for Poverty Action (IPA) es una organización internacional sin fines de lucro que descubre y promueve soluciones efectivas e innovadoras para las dificultades que enfrenta la población más vulnerable. En IPA evaluamos la efectividad de las intervenciones utilizando métodos rigurosos de evaluación de impacto. Desde la fundación de IPA en 2002, hemos trabajado con más de 600 académicos de las más prestigiosas instituciones, gestionando más de 830 evaluaciones en 51 países. En el futuro, nuestro crecimiento se concentrará en los países, como el Perú, en donde contamos con personal local e internacional, relaciones consolidadas con el gobierno, ONGs y el sector privado, así como un conocimiento profundo de la problemática local.
En el Perú hemos realizado investigaciones rigurosas y aplicadas en áreas de interés nacional, mientras construimos capacidades para generar y utilizar evidencia. En esta reseña del program país, presentamos ejemplos de proyectos que ofrecen evidencia útil sobre aspectos que afectan a la población más vulnerable de Perú.
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.
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.
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.
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.
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.
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.
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.
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.
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 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.
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.
We evaluate an intervention to raise young women’s economic empowerment in Sierra Leone, where women frequently experience sexual violence and face multiple economic disadvantages. The intervention provides them with a protective space (a club) where they can …nd support, receive information on health/reproductive issues and vocational training. Unexpectedly, the post-baseline period coincided with the 2014 Ebola outbreak. Our analysis leverages quasi-random across-village variation in the severity of Ebola-related disruption, and random assignment of villages to the intervention to document the impact of the Ebola outbreak on the economic lives of 4 700 women tracked over the crisis, and any ameliorating role played by the intervention. In highly disrupted control villages, the crisis leads younger girls to spend signi…cantly more time with men, out-of-wedlock pregnancies rise, and as a result, they experience a persistent 16pp drop in school enrolment post-crisis. These adverse e¤ects are almost entirely reversed in treated villages because the intervention enables young girls to allocate time away from men, preventing out-of-wedlock pregnancies and enabling them to re-enrol in school post-crisis. In treated villages, the unavailability of young women leads some older girls to use transactional sex as a coping strategy. The intervention causes them to increase contraceptive use so this does not translate into higher fertility. Our analysis pinpoints the mechanisms through which the severity of the aggregate shock impacts the economic lives of young women, and shows how interventions in times of crisis can interlink outcomes across younger and older cohorts. J