Value for Money An input from the Abdul Latif Jameel Poverty Action Lab Kamilla Gumede, J-PAL Africa

http://www.povertyactionlab.org/ Overview J-PAL specialises in impact evaluations of social programmes that make use of a randomised counterfactual Because we can measure the real impact of programmes, we can also assess programme efficacy and compare cost effectiveness of different programme approaches and policies Today, I will present two insights about value for money: Pricing of health products: Immunisation for health care products User fees for bednets Cross-subsidisation: Provision of health care services through schools

Pricing health products http://www.povertyactionlab.org/ Pricing health products Demand problem. Low demand for preventive health interventions Only a quarter of women in India breastfed their children within an hour of birth and the average period of exclusive breastfeeding is 2 months (WHO recommends 6 months of exclusive breastfeeding) Fraction of children receiving deworming medicine dropped from 78% to 59% when parents had to sign a form Immunisation for childhood diseases is one of the most cost effective health interventions, yet only 2% of children in Udaipur are fully immunised Unreliable service delivery may discourage usage Very high price-elasticity for preventive health services, both for positive prices and negative prices (something special about zero)

Absence rates for Teachers and Health Workers (based on nationally representative random checks) % Health workers Teachers Uganda Bangladesh India Indonesia Peru Ecuador GDP per capita, $PPP, 2005, WDI

Fixing supply or demand (?) http://www.povertyactionlab.org/ Fixing supply or demand (?) High rates of absenteeism in health clinics may explain low rate of immunisation: Seva Mandir teamed-up with the government to organise immunisation camps. Male nurses (on a motorcycle) collect vaccines from government facilities. They then hold an immunisation camp in the village. Monthly, always the same date. Very regular (95% of the planned camps took place). Announced by a local health worker who also tried to sensitise women to the need of getting children immunised. Incentives for immunisation: In some immunisation camps, Seva Mandir offered one kilogram of lentils to mothers who took their children to be immunised and a set of plates for completed immunisation. A very small reward would not convince people who are strongly against immunisation.

%-share who are fully immunised http://www.povertyactionlab.org/ %-share who are fully immunised

High price-elasticity and user fees http://www.povertyactionlab.org/ High price-elasticity and user fees User fees are advocated to promote sustainability of health services and to help make sure that goods and services are not wasted. But user fees is a barrier to access. Do fees screen out those who never intend to use the product, and target it to those who need it the most? Or does charging simply screen out the poor? Charging even very small user fees substantially reduces adoption. When a program in Kenya moved from free deworming in schools to charging an average of 30 cents per child, take-up fell from 75 to 19 percent. Cost sharing does not concentrate adoption on those who need products most. Families with children under 5 are not more likely to buy water disinfectant; the anemic are not more likely to buy bednets; children with high parasitic worm loads are no more likely to purchase deworming pills.

Positive prices discourage use: bednet This corresponds to the first graph multiplied by the second graph, essentially (effective coverage = ownership rate x usage rate). 50 Ksh – price at which PSI sells nets In the experiment prices only up to 40Ksh, but we can extrapolate the coverage rate at 50Ksh with our regression estimates.

Sustainability ?

http://www.povertyactionlab.org/ Cross-subsidisation MDGs for education seek to get 100% participation in primary school, and gender equality in education participation generally Worldwide, children enroll in primary education – but low attendance rates. Many interventions have been tried and found to work: Conditional cash transfers to poor families - through PROGRESA - in Mexico. Monthly cash payments are - in theory - conditional on school attendance and more. Free uniforms. Merit scholarship (for secondary education) in last years of primary education, intended to motivate school attendance. Mass school-based deworming.

Dollars per years of education

http://www.povertyactionlab.org/ Summary Budget officials play critical role in promoting value for money, as example: Shift away from curative to preventive health User fees can help get services to poor people, but not for all products and services Cross-subsidisation: health delivery through schools Environment of evidence based decision-making J-PAL ongoing research on deliveries in health facilities in Nigeria; incentives and monitoring for service providers; recruitment and retainment of community health workers in Zambia; supply-chains for health product in Uganda; and more What are key policy questions that we need scientific evidence on?

www.povertyactionlab.org J-PAL Africa Southern African Labour and Development Research Unit SALDRU University of Cape Town South Africa Tel: +27 21 650 5981 jpalafrica@povertyactionlab.org