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Asuming PO, Kim HB, Sim A. Selection and behavioral responses of health insurance subsidies in the long run: Evidence from a field experiment in Ghana. HEALTH ECONOMICS 2024; 33:992-1032. [PMID: 38291321 DOI: 10.1002/hec.4797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 11/09/2023] [Accepted: 12/19/2023] [Indexed: 02/01/2024]
Abstract
We study the effects of a health insurance subsidy in Ghana, where mandates are not enforceable. We randomly provide different levels of subsidy (1/3, 2/3, and full) and evaluate the impact at 7 months and 3 years after the intervention. We find that a one-time subsidy increased insurance enrollment for all groups in both the short and long runs, but health care utilization in the long run increased only for the partial subsidy group. We find supportive evidence that ex-post behavioral responses rather than ex-ante selective enrollment explain the long-run health care utilization results.
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Affiliation(s)
| | - Hyuncheol Bryant Kim
- Department of Economics, Hong Kong University of Science and Technology, Hong Kong, Hong Kong
| | - Armand Sim
- Centre for Development Economics and Sustainability, Monash University, Caulfield East, Victoria, Australia
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2
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Tiwari M. Financial incentives and delivery care: Evidence from the Safe Delivery Incentive Program in Nepal. HEALTH ECONOMICS 2023; 32:2372-2389. [PMID: 37421645 DOI: 10.1002/hec.4732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 05/18/2023] [Accepted: 06/20/2023] [Indexed: 07/10/2023]
Abstract
This paper examines the effects of the Safe Delivery Incentive Program in Nepal, a cash transfer program that reduced the costs of childbirth in healthcare facilities. Women giving birth for the first, second, or third time (below-cutoff) became eligible in 2005, and women giving birth for the fourth time or more (above-cutoff) became eligible two years later. Using a difference-in-differences design, I find that below-cutoff women in high Human Development Index (HDI) districts increased facility delivery by 8.8 percentage points. Despite larger cost reductions, below-cutoff women in low HDI districts did not increase facility delivery but increased home delivery with skilled personnel by 4.8 percentage points. The program had no impact on above-cutoff women, who become eligible 2 years into the program. I suggest that pre-existing barriers such as poor infrastructure of roads and facilities, customs, liquidity constraints, and lack of program awareness limited the program's effectiveness.
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Affiliation(s)
- Manda Tiwari
- Western Illinois University, Macomb, Illinois, USA
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3
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Suh H, Kalai S, Trivedi N, Underwood C, Hendrickson ZM. Effects of women's economic empowerment interventions on antenatal care outcomes: a systematic review. BMJ Open 2023; 13:e061693. [PMID: 36914184 PMCID: PMC10016312 DOI: 10.1136/bmjopen-2022-061693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Abstract
OBJECTIVES Early and adequate antenatal care (ANC) has been shown to reduce maternal morbidity and mortality globally. Increasing evidence suggests that women's economic empowerment (WEE) is a critical factor that may influence uptake of ANC during pregnancy. However, existing literature lacks a comprehensive synthesis of studies on WEE interventions and their effects on ANC outcomes. This systematic review analyses WEE interventions at the household, community and national levels and their effects on ANC outcomes in low-income and middle-income countries, where the majority of maternal deaths occur. METHODS Six electronic databases were systematically searched as well as 19 websites of relevant organisations. Studies published in English and after 2010 were included. RESULTS Following abstract and full-text review, 37 studies were included in this review. Seven studies used an experimental study design, 26 studies used a quasi-experimental study design, 1 study used an observational design and 1 study was a systematic review with meta-analysis. Thirty-one included studies evaluated a household-level intervention, and six studies evaluated a community-level intervention. No included studies examined a national-level intervention. CONCLUSION Most included studies on household-level and community-level interventions found a positive association between the intervention and the number of ANC visits women received. This review emphasises the need for more WEE interventions that empower women at the national level, for the expansion of the definition of WEE to be more inclusive of the multidimensionality of WEE interventions and the social determinants of health, and the standardisation of ANC outcome measurement globally.
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Affiliation(s)
- Heezy Suh
- Department of Public Health Studies, Johns Hopkins University, Baltimore, Maryland, USA
| | - Shiri Kalai
- Department of Public Health Studies, Johns Hopkins University, Baltimore, Maryland, USA
| | - Niki Trivedi
- Department of Public Health Studies, Johns Hopkins University, Baltimore, Maryland, USA
| | - Carol Underwood
- Center for Communication Programs, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Health, Behavior and Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Zoé Mistrale Hendrickson
- Center for Communication Programs, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Health, Behavior and Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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Lenel F, Priebe J, Satriawan E, Syamsulhakim E. Can mHealth campaigns improve CCT outcomes? Experimental evidence from sms-nudges in Indonesia. JOURNAL OF HEALTH ECONOMICS 2022; 86:102687. [PMID: 36242788 DOI: 10.1016/j.jhealeco.2022.102687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 09/05/2022] [Accepted: 09/13/2022] [Indexed: 06/16/2023]
Abstract
Employing a clustered RCT this paper examines the short-term impact of a 12-month mHealth BCC campaign on health practices & outcomes among CCT beneficiaries in Indonesia. Our analysis reveals that the intervention led to substantial improvements in maternal health behavior (postnatal care, child vaccinations, hygiene practices) & outcomes (anemia rates). Adopting a heterogeneous treatment effect framework, we further show that improvements in maternal hygiene practices and anemia rates are closely linked to health knowledge gained by mothers through the sms campaign. In contrast, we provide suggestive evidence that improvements in other health indicators are more likely to be related to the reminder and nudge components of the intervention.
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Affiliation(s)
| | - Jan Priebe
- Bernhard Nocht Institute for Tropical Medicine, Bernhard Nocht Straße 74, 20359 Hamburg, Germany.
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Rezaei SJ, de Walque D, Mateen FJ. Conditional cash transfers to improve health-focused outcomes: a global scoping review. Glob Public Health 2022; 17:3368-3385. [PMID: 35727705 DOI: 10.1080/17441692.2022.2092186] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This scoping review assesses the use of conditional cash transfer (CCT) interventions - direct distribution of money to individuals conditional on their compliance to certain requirements - in randomised controlled trials, quasi-experimental studies and large community-based randomised trials with health-focused outcomes. Five databases were searched to identify 68 records published 2004-2021 from 25 countries (8 low- (32%), 5 lower middle- (20%), 6 upper middle- (24%) and 6 high-income (24%), according to the World Bank Categorisation (2017). Forty-six studies were unique (after excluding multiple publications on a single study). The most common outcomes assessed were infectious diseases (30%); maternal health (24%); vaccination rates (17%); and childhood developmental measures (17%). The number of participants receiving CCT in each study ranged from 47 to 5,788, with a median of 487 individuals. The number of total participants ranged from 72 to 14,000, with a median of 1,289 individuals. Fifteen percent of studies involved mobile CCT disbursement. More than a quarter of payments were greater than 50 USD (29%), and most payments were 20 USD or less (58%). Seventy-eight percent of unique full-length studies reported statistically significant CCT effects. Although CCTs remain controversial, a growing evidence base is emerging for their potential impact in specific health conditions.
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Affiliation(s)
- Shawheen J Rezaei
- Massachusetts General Hospital, Department of Neurology, Boston, MA, USA
| | | | - Farrah J Mateen
- Massachusetts General Hospital, Department of Neurology, Boston, MA, USA
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Jacobs W, Downey LE. Impact of conditional cash transfer programmes on antenatal care service uptake in low and middle-income countries: a systematic review. BMJ Open 2022; 12:e064673. [PMID: 36428017 PMCID: PMC9703316 DOI: 10.1136/bmjopen-2022-064673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Antenatal care (ANC) is crucial to protecting the health of pregnant women and their unborn children; however, the uptake of ANC among pregnant women in low and middle-income countries (LMICs) is suboptimal. One popular strategy to increase the uptake of health services, including ANC visits, are conditional cash transfer (CCT) programmes. CCT programmes require beneficiaries to comply with certain conditionalities in order to receive a financial sum. A systematic review was carried out to determine whether CCT programmes have a positive impact on ANC uptake in LMIC populations. METHODS Electronic databases CENTRAL, MEDLINE, Embase, Maternity and Infant Care and Global Health were searched from database inception to 21 January 2022. Reference checking and grey literature searches were also applied. Eligible study designs were randomised controlled trials, controlled before-after studies and interrupted time series analysis. Risk of bias assessments were undertaken for each study by applying the Risk of Bias 2 tool and the Risk of Bias in Non-randomised Studies of Interventions tool. RESULTS Out of 1534 screened articles, 18 publications were included for analysis. Eight studies reported statistically non-significant results on all reported outcomes. Seven studies demonstrated statistically significant positive effects ranging from 5.5% to 45% increase in ANC service uptake. A further three studies reported small but statistically significant impact of CCT on the use of ANC services in both positive (2.5% increase) and negative (3.7% decrease) directions. Subanalysis of results disaggregated by socioeconomic status (SES) indicated that ANC attendance may be more markedly improved by CCT programmes in low SES populations; however, results were inconclusive. CONCLUSION Our evidence synthesis presented here demonstrated a highly heterogeneous evidence base pertaining to the impact of CCTs on ANC attendance. More high-powered studies are required to elucidate the true impact of CCT programmes on ANC uptake, with particular focus on the barriers and enablers of such programmes in achieving intended outcomes.
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Affiliation(s)
- Ward Jacobs
- School of Public Health, Imperial College London, London, UK
| | - Laura Emily Downey
- School of Public Health, Imperial College London, London, UK
- The George Institute for Global Health, Sydney, New South Wales, Australia
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Chandir S, Siddiqi DA, Abdullah S, Duflo E, Khan AJ, Glennerster R. Small mobile conditional cash transfers (mCCTs) of different amounts, schedules and design to improve routine childhood immunization coverage and timeliness of children aged 0-23 months in Pakistan: An open label multi-arm randomized controlled trial. EClinicalMedicine 2022; 50:101500. [PMID: 35784436 PMCID: PMC9241101 DOI: 10.1016/j.eclinm.2022.101500] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 05/17/2022] [Accepted: 05/19/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Cost-effective demand-side interventions are needed to increase childhood immunization. Multiple studies find tying income support programs (≥USD 50 per year) to immunization raises coverage. Research on maximizing impact from small mobile-based conditional cash transfers (mCCTs) (≤USD 15 per fully immunized child) delivered in lower-income settings remains sparse. METHODS Participants in Karachi, Pakistan, were individually randomized into a seven arm, factorial open label study with five mCCT arms, one reminder (SMS) only arm, and one control arm. The mCCT arms varied by amount (high ∼USD 15 per fully immunized child versus low ∼USD 5 per fully immunized child), schedule (flat versus rising payments over the schedule), design (certain versus lottery payments), and payment method (airtime or mobile money). Children were enrolled at BCG, pentavalent-1 (penta-1) or pentavalent-2 (penta-2) vaccination and followed until at least 18 months of age. A serosurvey in 15% sub-sample validated reported study coverage. The full immunization coverage (FIC) at 12 months (primary outcome) was analyzed using logit regression. ClinicalTrials.gov (NCT03355989), 3ie registry (58f6ee7725fc1), and AEA RCT Registry (AEARCTR-0001953). FINDINGS Between November 6, 2017, and October 10, 2018, a total of 11,197 caregiver-child pairs were enrolled, with 1598-1600 caregiver-child pairs per arm. FIC at 12 months was statistically significantly higher for any mCCT versus SMS (OR:1.18, 95% CI: 1.05-1.33; p = 0.005). Within the mCCT arms, FIC was statistically significantly higher for high versus low amount (OR: 1.16, 95% CI: 1.04-1.29; p = 0.007), certain versus lottery payment (OR: 1.30, 95% CI: 1.17-1.45; p < 0.001) and airtime versus mobile money (OR: 1.17, 95% CI:1.01-1.36; p = 0.043). There was no statistically significant difference between a flat and increasing schedule (OR: 1.03, 95% CI: 0.93-1.15; p = 0.550). SMS had a marginally statistically significant impact on FIC versus control (OR: 1.16, 95% CI: 1.00-1.35; p = 0.046). Findings were similar for up-to-date coverage of penta-3, measles-1 and measles-2 at 18 months. INTERPRETATION Small mCCTs (USD 0.8-2.4 per immunization visit) can increase FIC at 12 months and up-to-date coverage at 18 months at USD 23 per additional fully immunized child, in resource-constrained settings like Pakistan. Design details (certainty, schedule and delivery method of mCCTs) matter as much as the size of payments. FUNDING Global Innovation Fund, GiveWell.
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Affiliation(s)
- Subhash Chandir
- IRD Global, 583 Orchard Road, #06-01 Forum, Singapore, 238884
- Corresponding author at: IRD Global; 583 Orchard Road, #06-01 Forum, Singapore 238884.
| | | | - Sara Abdullah
- IRD Pakistan, 4th Floor Woodcraft Building, Korangi Creek, Karachi, 75190, Pakistan
| | - Esther Duflo
- MIT Department of Economics, room 544 Morris and Sophie Chang Building, 50 Memorial Drive, Cambridge, MA02142
| | | | - Rachel Glennerster
- MIT Department of Economics, room 544 Morris and Sophie Chang Building, 50 Memorial Drive, Cambridge, MA02142
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Shajarizadeh A, Grépin KA. The impact of institutional delivery on neonatal and maternal health outcomes: evidence from a road upgrade programme in India. BMJ Glob Health 2022; 7:bmjgh-2021-007926. [PMID: 35793838 PMCID: PMC9260806 DOI: 10.1136/bmjgh-2021-007926] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 05/14/2022] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Persistently high rates of neonatal and maternal mortality have been associated with home births in many low-income and middle-income countries (LMICs). However, causal evidence of the effect of institutional deliveries on neonatal and maternal health outcomes is limited in these settings. METHODS We investigate the effect of institutional deliveries on neonatal mortality and maternal postpartum complications in rural India using data from the 2015-2016 Indian Demographic and Health Survey and an instrumental variable methodology to overcome selection bias issues inherent in observational studies. Specifically, we exploit plausibly exogenous variation in exposure to a road upgrade programme that quasi-randomly upgraded roads to villages across India. RESULTS We find large effects of the road construction programme on the probability that a woman delivered in a health facility: moving from an unconnected village to a connected village increased the probability of an institutional delivery by 13 percentage points, with the biggest increases in institutional delivery observed in public hospitals and among women with lower levels of education and from poorer households. However, we find no evidence that increased institutional delivery rates improved rates of neonatal mortality or postpartum complications, regardless of whether the delivery occurred in a public or private facility, or if it was with a skilled birth attendant. CONCLUSION Policies that encourage institutional delivery do not always translate into increased health outcomes and should thus be complemented with efforts to improve the quality of care to improve neonatal and maternal health outcomes in LMICs.
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Affiliation(s)
| | - Karen Ann Grépin
- School of Public Health, University of Hong Kong Li Ka Shing Faculty of Medicine, Hong Kong, China
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Grépin KA, Chukwuma A, Holmlund M, Vera-Hernandez M, Wang Q, Rosa-Dias P. Estimating the impact of trained midwives and upgraded health facilities on institutional delivery rates in Nigeria using a quasi-experimental study design. BMJ Open 2022; 12:e053792. [PMID: 35613794 PMCID: PMC9125714 DOI: 10.1136/bmjopen-2021-053792] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES Studies have shown that demand-side interventions, such as conditional cash transfers and vouchers, can increase the proportion of women giving birth in a health facility in low-income and middle-income countries, but there is limited evidence of the effectiveness of supply-side interventions. We evaluated the impact of the Subsidy Reinvestment and Empowerment Programme Maternal and Child Health Project (SURE-P MCH) on rates of institutional delivery and antenatal care. DESIGN, SETTING AND PARTICIPANTS We used a differences-in-differences study design that compared changes in rates of institutional delivery and antenatal care in areas that had received additional support through the SURE-P MCH programme relative to areas that did not. Data on outcomes were obtained from the 2013 Nigerian Demographic and Health Survey. RESULTS We found that the programme significantly increased the proportion of women giving birth in a health facility by approximately 7 percentage points (p=0.069) or approximately 10% relative to the baseline after 9 months of implementation. The programme, however, did not significantly increase the use of antenatal care. CONCLUSION The findings of this study suggest there could be important improvements in institutional delivery rates through greater investment in supply-side interventions.
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Affiliation(s)
- Karen Ann Grépin
- School of Public Health, University of Hong Kong Li Ka Shing Faculty of Medicine, Hong Kong, China
| | - Adanna Chukwuma
- Health, Nutrition, and Population Global Practice, World Bank Group, Washington, DC, USA
| | - Marcus Holmlund
- Development Impact Evaluation (DIME), World Bank, Washington, District of Columbia, USA
| | | | - Qiao Wang
- Water Global Practice, World Bank Group, Washington, District of Columbia, USA
| | - Pedro Rosa-Dias
- Department of Economics and Public Policy and CHEPI, Imperial College Business School, Imperial College London, London, UK
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Vanhuyse F, Stirrup O, Odhiambo A, Palmer T, Dickin S, Skordis J, Batura N, Haghparast-Bidgoli H, Mwaki A, Copas A. Effectiveness of conditional cash transfers (Afya credits incentive) to retain women in the continuum of care during pregnancy, birth and the postnatal period in Kenya: a cluster-randomised trial. BMJ Open 2022; 12:e055921. [PMID: 34992119 PMCID: PMC8739676 DOI: 10.1136/bmjopen-2021-055921] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES Given high maternal and child mortality rates, we assessed the impact of conditional cash transfers (CCTs) to retain women in the continuum of care (antenatal care (ANC), delivery at facility, postnatal care (PNC) and child immunisation). DESIGN We conducted an unblinded 1:1 cluster-randomised controlled trial. SETTING 48 health facilities in Siaya County, Kenya were randomised. The trial ran from May 2017 to December 2019. PARTICIPANTS 2922 women were recruited to the control and 2522 to the intervention arm. INTERVENTIONS An electronic system recorded attendance and triggered payments to the participant's mobile for the intervention arm (US$4.5), and phone credit for the control arm (US$0.5). Eligibility criteria were resident in the catchment area and access to a mobile phone. PRIMARY OUTCOMES Primary outcomes were any ANC, delivery, any PNC between 4 and 12 months after delivery, childhood immunisation and referral attendance to other facilities for ANC or PNC. Given problems with the electronic system, primary outcomes were obtained from maternal clinic books if participants brought them to data extraction meetings (1257 (50%) of intervention and 1053 (36%) control arm participants). Attendance at referrals to other facilities is not reported because of limited data. RESULTS We found a significantly higher proportion of appointments attended for ANC (67% vs 60%, adjusted OR (aOR) 1.90; 95% CI 1.36 to 2.66) and child immunisation (88% vs 85%; aOR 1.74; 95% CI 1.10 to 2.77) in intervention than control arm. No intervention effect was seen considering delivery at the facility (90% vs 92%; aOR 0.58; 95% CI 0.25 to 1.33) and any PNC attendance (82% vs 81%; aOR 1.25; 95% CI 0.74 to 2.10) separately. The pooled OR across all attendance types was 1.64 (1.28 to 2.10). CONCLUSIONS Demand-side financing incentives, such as CCTs, can improve attendance for appointments. However, attention needs to be paid to the technology, the barriers that remain for delivery at facility and PNC visits and encouraging women to attend ANC visits within the recommended WHO timeframe. TRIAL REGISTRATION NCT03021070.
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Affiliation(s)
| | - Oliver Stirrup
- Institute for Global Health, University College London, London, UK
| | | | - Tom Palmer
- Institute for Global Health, University College London, London, UK
| | - Sarah Dickin
- Stockholm Environment Institute, Stockholm, Sweden
| | - Jolene Skordis
- Institute for Global Health, University College London, London, UK
| | - Neha Batura
- Institute for Global Health, University College London, London, UK
| | | | - Alex Mwaki
- Safe Water and AIDS Project, Kisumu, Kenya
| | - Andrew Copas
- Institute for Global Health, University College London, London, UK
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Palmer T, Batura N, Skordis J, Stirrup O, Vanhuyse F, Copas A, Odhiambo A, Ogendo N, Dickin S, Mwaki A, Haghparast-Bidgoli H. Economic evaluation of a conditional cash transfer to retain women in the continuum of care during pregnancy, birth and the postnatal period in Kenya. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000128. [PMID: 36962294 PMCID: PMC10021150 DOI: 10.1371/journal.pgph.0000128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 01/19/2022] [Indexed: 11/18/2022]
Abstract
There is limited evidence on the cost and cost-effectiveness of cash transfer programmes to improve maternal and child health in Kenya and other sub-Saharan African countries. This article presents the economic evaluation results of the Afya trial, assessing the costs, cost-effectiveness and equity impact of a demand-side financing intervention that promotes utilisation of maternal health services in rural Kenya. The cost of implementing the Afya intervention was estimated from a provider perspective. Cost data were collected prospectively from all implementing and non-implementing partners, and from health service providers. Cost-efficiency was analysed using cost-transfer ratios and cost per mother enrolled into the intervention. Cost-effectiveness was assessed as cost per additional eligible antenatal care visit as a result of the intervention, when compared with standard care. The equity impact of the intervention was also assessed using a multidimensional poverty index (MPI). Programme cost per mother enrolled was International (INT)$313 of which INT$ 92 consisted of direct transfer payments, suggesting a cost transfer ratio of 2.4. Direct healthcare utilisation costs reflected a small proportion of total provider costs, amounting to INT$ 21,756. The total provider cost of the Afya intervention was INT$808,942. The provider cost per additional eligible ANC visit was INT$1,035. This is substantially higher than estimated annual health expenditure per capita at the county level of $INT61. MPI estimates suggest around 27.4% of participant households were multidimensionally poor. MPI quintiles did not significantly modify the intervention effect, suggesting the impact of the intervention did not differ by socioeconomic status. Based on the available evidence, it is not possible to conclude whether the Afya intervention was cost-effective. A simple comparison with current health expenditure in Siaya county suggests that the intervention as implemented is likely to be unaffordable. Consideration needs to be given to strengthening the supply-side of the cash transfer intervention before replication or uptake at scale.
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Affiliation(s)
- Tom Palmer
- Institute for Global Health, University College London, London, United Kingdom
| | - Neha Batura
- Institute for Global Health, University College London, London, United Kingdom
| | - Jolene Skordis
- Institute for Global Health, University College London, London, United Kingdom
| | - Oliver Stirrup
- Institute for Global Health, University College London, London, United Kingdom
| | | | - Andrew Copas
- Institute for Global Health, University College London, London, United Kingdom
| | | | | | - Sarah Dickin
- Stockholm Environment Institute, Stockholm, Sweden
| | - Alex Mwaki
- Safe Water and AIDS Project (SWAP), Kisumu, Kenya
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Lee S, Adam AJ. Designing a Logic Model for Mobile Maternal Health e-Voucher Programs in Low- and Middle-Income Countries: An Interpretive Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 19:295. [PMID: 35010561 PMCID: PMC8744962 DOI: 10.3390/ijerph19010295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 12/25/2021] [Accepted: 12/26/2021] [Indexed: 06/14/2023]
Abstract
Despite the increasing transition from paper vouchers to mobile e-vouchers for maternal health in low- and middle-income countries, few studies have reviewed key elements for program planning, implementation, and evaluation. To bridge this gap, this study conducted an interpretive review and developed a logic model for mobile maternal health e-voucher programs. Pubmed, EMBASE, and Cochrane databases were searched to retrieve relevant studies; 27 maternal health voucher programs from 84 studies were identified, and key elements for the logic model were retrieved and organized systematically. Some of the elements identified have the potential to be improved greatly by shifting to mobile e-vouchers, such as payment via mobile money or electronic claims processing and data entry for registration. The advantages of transitioning to mobile e-voucher identified from the logic model can be summarized as scalability, transparency, and flexibility. The present study contributes to the literature by providing insights into program planning, implementation, and evaluation for mobile maternal health e-voucher programs.
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Affiliation(s)
- Seohyun Lee
- Department of Global Public Administration, Mirae Campus, Yonsei University, Wonju 26493, Korea
| | - Abdul-jabiru Adam
- Department of Public Administration, Mirae Campus, Yonsei University Graduate School, Wonju 26493, Korea;
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Okeke EN. Money and my mind: Maternal cash transfers and mental health. HEALTH ECONOMICS 2021; 30:2879-2904. [PMID: 34462990 PMCID: PMC9291569 DOI: 10.1002/hec.4398] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 06/14/2021] [Accepted: 07/05/2021] [Indexed: 05/30/2023]
Abstract
This paper documents important mental health spillovers in the context of a program that offered pregnant women modest cash incentives to use pre- and perinatal health care services. Program participation was randomized and the payments were made after the birth of the child (and after the completion of an endline mental health assessment). I present causal evidence that the program led to improvements in mothers' mental health. The effect size ranges from a 1-3 percentage point reduction in postpartum depression measured using the Edinburgh Postnatal Depression Scale. I present suggestive evidence that these beneficial effects on mental health may be related to program-induced improvements in child health. These results provide novel evidence that programs designed to improve birth outcomes may generate unanticipated spillover effects on mental health.
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Affiliation(s)
- Edward N. Okeke
- Department of Economics, Sociology and StatisticsRANDSanta MonicaCaliforniaUSA
- Pardee RAND Graduate SchoolRANDSanta MonicaCaliforniaUSA
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14
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McGuire F, Kreif N, Smith PC. The effect of distance on maternal institutional delivery choice: Evidence from Malawi. HEALTH ECONOMICS 2021; 30:2144-2167. [PMID: 34096127 DOI: 10.1002/hec.4368] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 05/18/2021] [Accepted: 05/24/2021] [Indexed: 06/12/2023]
Abstract
In many low- and middle-income countries, geographical accessibility continues to be a barrier to health care utilization. In this paper, we aim to better understand the full relationship between distance to providers and utilization of maternal delivery services. We address three methodological challenges: non-linear effects between distance and utilization; unobserved heterogeneity through non-random distance "assignment"; and heterogeneous effects of distance. Linking Malawi Demographic Health Survey household data to Service Provision Assessment facility data, we consider distance as a continuous treatment variable, estimating a Dose-Response Function based on generalized propensity scores, allowing exploration of non-linearities in the effect of an increment in distance at different distance exposures. Using an instrumental variables approach, we examine the potential for unobserved differences between women residing at different distances to health facilities. Our results suggest distance significantly reduces the probability of having a facility delivery, with evidence of non-linearities in the effect. The negative relationship is shown to be particularly strong for women with poor health knowledge and lower socio-economic status, with important implications for equity. We also find evidence of potential unobserved confounding, suggesting that methods that ignore such confounding may underestimate the effect of distance on the utilization of health services.
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Affiliation(s)
- Finn McGuire
- Centre for Health Economics, University of York, York, UK
- Department of Economics, University of York, York, UK
| | - Noemi Kreif
- Centre for Health Economics, University of York, York, UK
| | - Peter C Smith
- Centre for Health Economics, University of York, York, UK
- Imperial College Business School, Imperial College, London, UK
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von Haaren P, Klonner S. Lessons learned? Intended and unintended effects of India's second-generation maternal cash transfer scheme. HEALTH ECONOMICS 2021; 30:2468-2486. [PMID: 34278651 DOI: 10.1002/hec.4390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 06/08/2021] [Accepted: 06/22/2021] [Indexed: 06/13/2023]
Abstract
The maternity benefit scheme piloted as Indira Gandhi Matritva Sahyog Yojana (IGMSY) since 2011 and recently rolled out as Pradhan Mantri Matru Vandana Yojana (PMMVY) incentivizes mothers to participate in infant health-promoting activities. It has become India's largest conditional cash transfer program ever, outrivaling the country's first-generation maternity benefit scheme Janani Suraksha Yojana (JSY), which incentivizes institutional delivery and has been criticized for its unintended side effects on fertility. We approach IGMSY's geographically targeted pilot phase as a natural experiment and use data from a large national health survey to estimate its effects by a matched-pair difference-in-differences approach. Consistent with the program's conditions, we find increases in infant immunization. As side effect, long-term utilization of public health facilities becomes more frequent and intervals between eligible births increase by 17%. Our findings suggest that India'ns second-generation maternity benefit scheme has been more carefully designed than its predecessor, with side effects that support the program's broader objectives. But both direct and indirect effects are small and can make only a small contribution to redressing India's dismal maternal and child health record.
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Affiliation(s)
- Paula von Haaren
- Department of Development Economics, South Asia Institute, Heidelberg University, Heidelberg, Germany
| | - Stefan Klonner
- Department of Development Economics, South Asia Institute, Heidelberg University, Heidelberg, Germany
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Croke K, Telaye Mengistu A, O'Connell SD, Tafere K. The impact of a health facility construction campaign on health service utilisation and outcomes: analysis of spatially linked survey and facility location data in Ethiopia. BMJ Glob Health 2021; 5:bmjgh-2020-002430. [PMID: 32859649 PMCID: PMC7454195 DOI: 10.1136/bmjgh-2020-002430] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 05/21/2020] [Accepted: 05/23/2020] [Indexed: 11/03/2022] Open
Abstract
Background Access to health facilities in many low-income and middle-income countries remains low, with a strong association between individuals’ distance to facilities and health outcomes. Yet plausibly causal estimates of the effects of facility construction programmes are rare. Starting in 2004, more than 2800 government health facilities were built in Ethiopia. This study estimates the impact of this programme on maternal health service utilisation and birth outcomes. Methods We analyse the impact of Ethiopia’s health centre construction programme on health service utilisation and outcomes, using a difference-in-difference design. We match facility opening years to child birth years in four rounds of Demographic and Health Surveys (DHS) using georeferenced data. We also use event study models to test for pre-trends in the outcomes of interest. Results Opening of new health facilities within 5 km increases facility delivery by 7.2 percentage points (95% CI 5.2 to 9.1) and antenatal care by 0.38 visits (95% CI 0.24 to 0.52). It is not significantly associated with changes in caesarean section births or neonatal mortality. Opening of district hospitals increases facility delivery by 18.2 percentage points (95% CI 12.7 to 23.7), and caesarean section births by 6.8 percentage points (95% CI 2.5 to 11.2), but is not associated with reduction of neonatal mortality. Conclusions Ethiopia’s facility construction program improved access to antenatal and delivery care. However, there was no detectable association between facility construction and neonatal mortality. Increased access to care must be combined with health system quality improvements and broader social development initiatives to sustainably improve health outcomes.
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Affiliation(s)
- Kevin Croke
- Global Health and Population, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | | | | | - Kibrom Tafere
- Development Economics Group, World Bank Group, Washington, DC, USA
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Zuñiga JA, García A, Kyololo OM, Hamilton-Solum P, Kabimba A, Milimo B, Abbyad CW, Reid DD, Chelagat D. Increasing utilisation of skilled attendants at birth in sub-Saharan Africa: A systematic review of interventions. Int J Nurs Stud 2021; 120:103977. [PMID: 34144356 DOI: 10.1016/j.ijnurstu.2021.103977] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 04/21/2021] [Accepted: 05/01/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Maternal mortality is a critical global public health concern, especially in low- and middle-income countries in sub-Saharan Africa. Although maternal mortality rates have declined by approximately 39% in sub-Saharan Africa over the last decade, maternal deaths during pregnancy and in childbirth remain high. Interventions to improve mothers' use of skilled birth attendants may decrease maternal mortality in sub-Saharan African countries. OBJECTIVES This systematic literature review examines components of and evaluates the effectiveness of interventions to increase use of skilled birth attendants in sub-Saharan Africa. METHODS Guided by the PRISMA model for systematic reviews, the PubMed, Web of Science, and CIHNAL databases were searched for studies from years 2003 through June 2020. RESULTS The 28 articles included in this review reported on interventions incorporating community health workers, phone or text messages, implementation of community-level initiatives, free health care, cash incentives, an international multi-disciplinary volunteer team, and a group home for pregnant women, which improved use of skilled birth attendants to varying degrees. Only one study reported improved outcomes with the use of community health workers. All of the interventions using text messages increased hospital utilization for births. CONCLUSIONS Interventions implemented in sub-Saharan Africa hold promise for improving maternal health. Multi-level interventions that involve community members and local leaders can help address the multi-faceted issue of poor maternal health outcomes and mortality. Interventions should focus on capacity building and on training and mentoring of formally-trained health care providers and community health workers in order to expand access.
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Affiliation(s)
- Julie A Zuñiga
- School of Nursing, The University of Texas at Austin, 1710 Red River, Austin 78712, TX, United States.
| | - Alexandra García
- School of Nursing, The University of Texas at Austin, 1710 Red River, Austin 78712, TX, United States
| | | | - Patricia Hamilton-Solum
- School of Nursing, The University of Texas at Austin, 1710 Red River, Austin 78712, TX, United States
| | - Anne Kabimba
- School of Nursing, Moi University, Eldoret Kenya, Kenya
| | - Benson Milimo
- School of Nursing, Moi University, Eldoret Kenya, Kenya
| | - Christine W Abbyad
- School of Nursing, The University of Texas at Austin, 1710 Red River, Austin 78712, TX, United States
| | - Davika D Reid
- School of Nursing, The University of Texas at Austin, 1710 Red River, Austin 78712, TX, United States
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Mobile Money Use and Healthcare Utilization: Evidence from Rural Uganda. SUSTAINABILITY 2020. [DOI: 10.3390/su12093741] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Lack of cash on hand is a significant obstacle in accessing healthcare services in developing countries. Many expectant mothers in the least developed countries do not receive sufficient care during pregnancy due to financial constraints. If such hurdles in accessing healthcare can be overcome, it will contribute to reduction in maternal and newborn mortality, which is a key target of Sustainable Development Goal 3. This study reports the first assessment of the impact of mobile money services on maternal care utilization. We hypothesize that mobile money adoption would motivate rural Ugandan women to receive antenatal care and to deliver their children at health facilities or with skilled birth attendants. By receiving remittances utilizing mobile money, poor rural households may obtain more cash in hand, which might change women’s health-seeking behavior. We apply community- and mother-fixed effects models with heterogeneity analysis to longitudinal panel data (the RePEAT [Research on Poverty, Environment, and Agricultural Technology] survey) of three waves (2009, 2012, and 2015). The analysis uses pregnancy reports of 2007–2015 from 586 rural Ugandan households. We find suggestive evidence that mobile money adoption positively affects the take-up of antenatal care. Heterogeneity analysis indicates that mobile money brings a larger benefit to geographically challenged households by easing their liquidity constraint as they face higher cost of traveling to distant health facilities. The models failed to reject the null hypothesis of no mobile money effect on the delivery-related outcome variables. This study suggests that promoting financial inclusion by means of mobile money motivates women in rural and remote areas to make antenatal care visits while the evidence of such effect is not found for take-up of facility delivery or delivery with skilled birth attendants.
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Cooper JE, Benmarhnia T, Koski A, King NB. Cash transfer programs have differential effects on health: A review of the literature from low and middle-income countries. Soc Sci Med 2020; 247:112806. [PMID: 32086171 DOI: 10.1016/j.socscimed.2020.112806] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 10/10/2019] [Accepted: 01/14/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Cash transfer programs have grown increasingly popular and are now used as interventions to target a wide array of health outcomes across many diverse settings. However, cash transfer experiments have yielded mixed results, highlighting gaps in our understanding of how these programs work. In particular, we do not yet know whether cash transfers are more effective for certain health outcomes compared to others, or are more effective for some population subgroups compared to others. Here, we ask whether the effects of cash transfers on health outcomes differ across study subgroups. METHODS We reviewed the literature on cash transfer experiments conducted in low and middle income countries, published in English between 1985 and 2015. We documented whether the investigators reported either i) stratum-specific estimates or ii) the interaction term between subgroups and exposure to the intervention. For studies that presented stratum-specific estimates without statistical tests for heterogeneity, we assessed heterogeneity across subgroups with a Cochran Q test. RESULTS Of the 56 studies we reviewed, 40 reported effects on study subgroups. The majority of the cash transfer interventions had different magnitudes of effects on health across subgroups. This heterogeneity was often underreported or not formally analyzed. We find substantial heterogeneity of cash transfers on child health and on adult health yet little heterogeneity of cash transfers on sexual and reproductive health. CONCLUSIONS Accounting for the heterogeneous impacts of cash transfers during program design and evaluation is necessary to better target cash transfer programs and generate more precise data on their effects.
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Affiliation(s)
- Jan E Cooper
- School of Public Health, University of California at Berkeley, Berkeley, CA, USA; Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA, 20115, USA.
| | - Tarik Benmarhnia
- Department of Family Medicine and Public Health & Scripps Institution of Oceanography University of California, San Diego, CA, USA.
| | - Alissa Koski
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada.
| | - Nicholas B King
- Biomedical Ethics Unit & Department of Social Science and Medicine, McGill University, Montreal, Quebec, Canada.
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Masaba BB, Mmusi-Phetoe RM. Free Maternal Health Care Policy in Kenya; Level of Utilization and Barriers. INTERNATIONAL JOURNAL OF AFRICA NURSING SCIENCES 2020. [DOI: 10.1016/j.ijans.2020.100234] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
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Le Port A, Zongrone A, Savy M, Fortin S, Kameli Y, Sessou E, Diatta AD, Koulidiati JL, Kodjo NE, Kamayera F, Mahamadou T, Martin-Prevel Y, Ruel MT. Program Impact Pathway Analysis Reveals Implementation Challenges that Limited the Incentive Value of Conditional Cash Transfers Aimed at Improving Maternal and Child Health Care Use in Mali. Curr Dev Nutr 2019; 3:nzz084. [PMID: 31528837 PMCID: PMC6735791 DOI: 10.1093/cdn/nzz084] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 07/11/2019] [Accepted: 07/15/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The program "Santé Nutritionnelle à Assise Communautaire à Kayes" (SNACK) in Mali aimed to improve child linear growth through a set of interventions targeted to mothers and children during pregnancy and up to the child's second birthday. Distributions of cash to mothers and/or lipid-based nutrient supplement to children 6-23 mo of age were added to SNACK to increase attendance at community health centers (CHCs). OBJECTIVES The aim of this study, which was embedded in a cluster-randomized impact evaluation of the program, was to assess the incentive value of the cash in relation to CHC attendance. METHODS We used a mixed-methods approach. We collected quantitative data on cash receipt and CHC attendance in a midline survey of mother-child pairs (n = 3443). A program impact pathway analysis guided qualitative data collection and analysis. Twelve CHCs were purposively selected in study groups that received cash. We conducted semistructured continuous observations of cash distributions in 11 CHCs (n = 22) and semistructured qualitative interviews with frontline workers (FLWs) (n = 71) and mothers (n = 22) who were purposively selected from the midline survey. RESULTS FLWs' knowledge of the objective and implementation plan of the cash program component was limited. A challenging physical environment and insufficient cash available for each distribution were identified as causes of irregularities in cash distributions. Most mothers mentioned having to return several times to receive their cash. Child health was identified as the main motivation to attend CHCs and cash was described as an additional benefit. CONCLUSION Implementation constraints related to remoteness and inaccessibility may have undermined the incentive value of the cash transfers in the SNACK program. Additional research is needed to identify interventions that not only incentivize mothers to participate but that can be implemented effectively and with high quality in challenging contexts such as rural areas of Mali.
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Affiliation(s)
- Agnes Le Port
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Dakar, Senegal
| | - Amanda Zongrone
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Dakar, Senegal
| | - Mathilde Savy
- UMR204 “Nutripass” (IRD-UM-SupAgro), French National Research Institute for Sustainable Development, Montpellier, France
| | - Sonia Fortin
- UMR204 “Nutripass” (IRD-UM-SupAgro), French National Research Institute for Sustainable Development, Montpellier, France
| | - Yves Kameli
- UMR204 “Nutripass” (IRD-UM-SupAgro), French National Research Institute for Sustainable Development, Montpellier, France
| | - Eric Sessou
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Dakar, Senegal
| | - Ampa Dogui Diatta
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Dakar, Senegal
| | | | | | | | | | - Yves Martin-Prevel
- UMR204 “Nutripass” (IRD-UM-SupAgro), French National Research Institute for Sustainable Development, Montpellier, France
| | - Marie T Ruel
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, DC, USA
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