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.
The results are in for the Community Health Assistant (CHA) incentives evaluation: increases in the productivity of CHAs that were recruited via career (versus social) incentives are mirrored by significantly improved health outcomes at the household level.
Both under- and over-treatment of communicable diseases are public bads. But efforts to decrease one run the risk of increasing the other. Using rich experimental data on household treatment-seeking behavior in Kenya, we study the implications of this trade-off for subsidizing life-saving antimalarials sold over-the-counter at retail drug outlets. We show that a very high subsidy (such as the one under consideration by the international community) dramatically increases access, but nearly one-half of subsidized pills go to patients without malaria. We study two ways to better target subsidized drugs: reducing the subsidy level, and introducing rapid malaria tests over-the-counter.
Poor sanitation contributes to morbidity and mortality in the developing world, but there is disagreement on what policies can increase sanitation coverage. To measure the effects of alternative policies on investment in hygienic latrines, we assigned 380 communities in rural Bangladesh to different marketing treatments—community motivation and information; subsidies; a supply-side market access intervention; and a control—in a cluster-randomized trial. Community motivation alone did not increase hygienic latrine ownership (+1.6 percentage points, P = 0.43), nor did the supply-side intervention (+0.3 percentage points, P = 0.90). Subsidies to the majority of the landless poor increased ownership among subsidized households (+22.0 percentage points, P < 0.001) and their unsubsidized neighbors (+8.5 percentage points, P = 0.001), which suggests that investment decisions are interlinked across neighbors. Subsidies also reduced open defecation by 14 percentage points (P < 0.001).
Beginning with the seminal article in 1971 by Lucas and Prescott, economists have examined investments under uncertainty in a variety of contexts. Becker et al. (1977) applied this concept to marriage suggesting that increased uncertainty in marriage (i.e., the likelihood of separation or divorce) reduces the incentive for spouses to invest in marriagespecific capital. Several studies have found that reducing the barriers to marital dissolution, through no-fault divorce laws for example, is associated with lower investments in marriage-specific goods (Landes, 1978; Johnson and Skinner, 1986; Peters, 1986; Lommerud, 1988; Lundberg and Rose, 1999; Stevenson, 2007).1 Similar studies have found that with greater uncertainty about paternity, 1 Other papers in economics have examined the impact of outside options in marriage and contracts affecting marital outcomes (Rasul, 2006; Rasul and Mathoushek, 2008; South and Lloyd, 1995). men are less willing to invest in their alleged offspring and more likely to divorce their wives (Alexander, 1974; Anderson et al., 2005). In this paper we examine the relationship between uncertainty and marriage stability in rural Malawi. In particular, we examine how uncertainty about a spouses’ HIV status, and thus the risk of HIV exposure, affects the likelihood of divorce.
UsingarandomizedevaluationinKenya, wemeasurehealthimpacts ofspring protection, an investment that improves source water quality. We also estimate households’ valuation of spring protection and simulate the welfare impacts of alternatives tothe current system of common property rights in water, which limits incentives for private investment. Spring infrastructure investments reduce fecal contamination by 66%, but household water quality improves less, due to recontamination. Child diarrhea falls by one quarter. Travel-cost based revealed preference estimates of households’ valuations are much smaller than both stated preference valuations and health planners’ valuations, and are consistent with models in which the demand for health is highly income elastic. We estimate that private property norms would generate little additional investment while imposing large static costs due to above-marginal-cost pricing, private property would function better at higher income levels or under water scarcity, andalternative institutions couldyieldParetoimprovements. JEL Codes: C93, H75, O13, Q25, Q51.
Short-run subsidies for health products are common in poor countries. How do they affect long-run adoption? A common fear among development practitioners is that one-off subsidies may negatively affect long-run adoption through referencedependence: People might anchor around the subsidized price and be unwilling to pay more for the product later. But for experience goods, one-off subsidies could also boost long-run adoption through learning. This paper uses data from a two-stage randomized pricing experiment in Kenya to estimate the relative importance of these effects for a new, improved antimalarial bed net. Reduced form estimates show that a one-time subsidy has a positive impact on willingness to pay a year later inherit. To separately identify the learning and anchoring effects, we estimate a parsimonious experiencegood model. Estimation results show a large, positive learning effect but no anchoring. We black then discuss the types of products and the contexts inherit for which these results may apply.
We conduct a field experiment to evaluate the effect of extrinsic rewards, both financial and non-financial, on the performance of agents recruited by a public health organization to promote HIV prevention and sell condoms. In this setting: (i) non-financial rewards are effective at improving performance; (ii) the effect of both rewards is stronger for pro-socially motivated agents; (iii) the effect of both rewards is stronger when their relative value is higher. The findings illustrate that extrinsic rewards can improve the performance of agents engaged in public service delivery, and that non-financial rewards can be effective in settings where the power of financial incentives is limited.
Background: Low rates of adherence to artemisinin-based combination therapy (ACT) regimens increase the risk of treatment failure and may lead to drug resistance, threatening the sustainability of current anti-malarial efforts. We assessed the impact of text message reminders on adherence to ACT regimens.
Methods: Health workers at hospitals, clinics, pharmacies, and other stationary ACT distributors in Tamale, Ghana provided flyers advertising free mobile health information to individuals receiving malaria treatment. The messaging system automatically randomized self-enrolled individuals to the control group or the treatment group with equal probability; those in the treatment group were further randomly assigned to receive a simple text message reminder or the simple reminder plus an additional statement about adherence in 12-hour intervals. The main outcome was self-reported adherence based on follow-up interviews occurring three days after treatment initiation. We estimated the impact of the messages on treatment completion using logistic regression.
Results: 1140 individuals enrolled in both the study and the text reminder system. Among individuals in the control group, 61.5% took the full course of treatment. The simple text message reminders increased the odds of adherence (adjusted OR 1.45, 95% CI [1.03 to 2.04], p-value 0.028). Receiving an additional message did not result in a significant change in adherence (adjusted OR 0.77, 95% CI [0.50 to 1.20], p-value 0.252).
Conclusion: The results of this study suggest that a simple text message reminder can increase adherence to antimalarial treatment and that additional information included in messages does not have a significant impact on completion of ACT treatment. Further research is needed to develop the most effective text message content and frequency.
Declining fertility in both the developed and developing world has led to large and potentially welfare-enhancing changes in women’s labor supply, education and investment in children in recent decades. However, it has been widely noted that the pace of this decline has stalled even while access to contraception has continued to expand, raising the question of whether increasing access to contraception is sufficient to lead to declining fertility. This paper provides evidence about the relationship between contraceptive access and fertility from a randomized controlled trial in Lusaka, Zambia, in which women of child-bearing age were provided with a voucher for free and immediate access to long-acting forms of contraception; this voucher was provided either to the woman individually, or the woman jointly with her spouse. Results show that there is a significant increase in contraceptive use, and a particularly large increase in experimentation with new contraceptive methods, but no decline in births in the short- or long-term compared to a control group who did not receive increased access to contraceptives.
Hunger during pre-harvest lean seasons is widespread in the agrarian areas of Asia and Sub-Saharan Africa. We randomly assign an $8.50 incentive to households in rural Bangladesh to temporarily out-migrate during the lean season. The incentive induces 22% of households to send a seasonal migrant, their consumption at the origin increases significantly, and treated households are 8–10 percentage points more likely to re-migrate 1 and 3 years after the incentive is removed. These facts can be explained qualitatively by a model in which migration is risky, mitigating risk requires individual-specific learning, and some migrants are sufficiently close to subsistence that failed migration is very costly. We document evidence consistent with this model using heterogeneity analysis and additional experimental variation, but calibrations with forward-looking households that can save up to migrate suggest that it is difficult for the model to quantitatively match the data. We conclude with extensions to the model that could provide a better quantitative accounting of the behavior.
Cash transfers directed to female caregivers in Nicaragua led to gains in child-development outcomes that persisted beyond the duration of the program.
Early childhood is a critical period for investment in human development, the circumstances of which can have lifelong impacts. Physical, cognitive, or behavioral delays in development can result in long-term negative effects on health, educational attainment, labor-market outcomes, and other indicators of well-being.
Conditional cash transfer (cct) programs are one way to help parents who lack resources invest more in their children. These programs provide families with cash grants as long as they undertake certain activities such as having their children attend regular health check-ups. While there is a large body of evidence on the short-term impacts of ccts on children’s development, there is less evidence on their long-term impacts. To better understand the effects of ccts later in life, researchers evaluated two distinct cct programs in Nicaragua.
In the first evaluation, researchers Tania Barham (University of Colorado Boulder), J-PAL affiliate Karen Macours (Paris School of Economics), and John A. Maluccio (Middlebury College), examined the long-term impacts of ccts on child development. In this study, they tested whether there is a critical window of time (the first 1,000 days from in utero to age two) for cognitive and physical development by taking advantage of the random assignment of households to receive cash transfers in either an “early” or “late" treatment group. In the second evaluation, Karen Macours, Norbert Schady (Inter-American Development Bank), and Renos Vakis (World Bank) studied a cct program with three variations to understand the channels through which different program components impacted early childhood development.