Kevin Croke World Bank kcroke@worldbank.org Long run educational gains from malaria control in Tanzania: Preliminary results CSAE Conference March 19, 2013 Kevin Croke World Bank kcroke@worldbank.org

motivation Major push on malaria control in Africa over past decade Well-established health benefits of insecticide treated nets (ITNs) Any reason to expect non-health impacts? Literature on early childhood health and long run outcomes Deworming (Ozier 2012; Baird et al 2011); Nutrition (Yang and Maccini 2009; Alderman et al 2006; many others) Malaria: Lucas, Kremer et al, Bleakley (all 2010) show educational or labor impacts from earlier generation of malaria control in Latin America and South Asia Can we trace the impact of recent malaria interventions on current learning outcomes?

Malaria control in Tanzania 1997-1999: Pilot social marketing of insecticide treated bed nets in two districts. 2000-2008: national scale up of social marketing (SMITN- SMARTNET and TNVS projects) 2008-2011: Mass free ITN distribution to all children, then all sleeping spaces Challenges No blanket simultaneous national treatment or randomized roll out Can we exploit “semi-phased” nature of roll out to identify impact on non-health outcomes? We would need a large scale, comprehensive national data set

The Uwezo test Initiative of donor consortium (Hewlett, DFID, CIDA, others) to measure learning outcomes, modeled on India’s ASER test Under aegis of Tanzanian NGO Twaweza 2010 – 2014 annual test in Tanzania, Uganda, and Kenya In order to generate district-level results, very large sample size needed 2011 Tanzania test: 77,000 households, 128,000 children See more at www.uwezo.net Survey Sample size frequency Representativeness DHS 10,000 3-5 years Regional level Household Budget Survey/National Panel Survey 2,000-3,200 Previously 7-10 years; now every 2 years Urban/rural Uwezo survey 80,000 households, 128,000 children Every year, 2010-2014 District level

The KINET project Social marketing of insecticide treated bed nets in Kilombero and Ulanga (“KINET”) ITNs sold for $5 (33% discount), treatment kits for $0.42, through private sector and by door-to-door promotion Results in Kilombero and Ulanga district surveillance area: From very low ITN coverage (~10%) to high coverage (>60%) over two year period. Malaria prevalence drops from 63%  38% for children under 2. Anemia drops from 49%  26% References: Schellenberg, J.R.M. Armstrong, S. Abdulla, H. Minja, R. Nathan, O. Mukasa, T. Marchant, H. Mponda, et al. 1999. “KINET: a Social Marketing Programme of Treated Nets and Net Treatment for Malaria Control in Tanzania, with Evaluation of Child Health and Long-term Survival.” Transactions of the Royal Society of Tropical Medicine and Hygiene 93 (3) (May): 225–231.

empirical model Uwezo (2011) captures outcome data for 128,000 children in Tanzania between ages 7-16 Given phased roll out, some district x cohort combinations have been protected by ITNs, others have not Exogenous shock/discontinuity separating 15-16 year old cohort (born in 1995-1996) in Kilombero and Ulanga from younger cohorts They were born too soon to benefit from KINET Hence a difference-in-difference estimation strategy 2011 Uwezo score = β + β1(“progam” cohort) + β2 (Kilombero/Ulanga dummy +β3 (Kilombero/Ulanga dummy*program cohort) + β4 (χ1) +ε

Table 1: Differential exposure to the KINET program across age cohorts Age in 1997 (when KINET introduced) Year of birth Age in 2011 Max years exposed to program from ages 0-2 (Kil/Ulanga) Max years exposed to program from ages 0-2 (other districts) Not born 2004 7 2 2003 8 2002 9 2001 10 2000 11 1999 12 -1 1998 13 1997 14 1 1996 15 1995 16

Results: KINET program   (1) (2) (3) (4) Kilombero/Ulanga protected cohort 0.2000*** 0.1881*** 0.1557*** 0.2013* (0.0711) (0.0717) (0.0572) (0.1177) Kilombero/Ulanga district -0.0927 0.0876 0.0462 -0.0393 (0.2235) (0.2293) (0.2472) ITN protected cohort 0.6003*** 0.6081*** 0.5648*** 0.6032*** (0.0392) (0.0385) (0.0442) (0.0382) village has tarmac road 0.1690*** (0.0569) 2011 school funding 0.0000*** (0.0000) distance district capital -0.0019*** (0.0005) secondary school in village 0.1697*** (0.0367) Has donor project -0.0462 (0.0432) Regional dummies no yes Additional controls Observations 94186 65441 66659 r2 0.4817 0.4935 0.4927 0.4943

Post-pilot scale up Based on success of KINET, social marketing scaled up nationally SMITN/SMARTNET program: 2000-2008 Tanzania National Voucher Scheme 2004-present No clear programmatic phase-in by region Predictors of high coverage rates: urban “council” district, KINET program, capital city, or proximity to Tanga/Mwanza

Results: post-2000 scale up   (1) (2) (3) (4) Kilombero/Ulanga x protected cohorts 0.1889*** 0.1599*** 0.1880*** 0.1638*** (0.0710) (0.0528) (0.0709) (0.0507) post-2000 high coverage dist. x cohort 0.1161 0.2192 (0.1657) (0.2342) post-2000 high ITN coverage dist. x cohort 0.0322 -0.0050 (0.0256) (0.0453) Regional dummies yes Yes Standard controls School and community controls no Observations 94186 65441 r2 0.4936 0.4930 0.4932 0.4810

robustness Unrelated variables test Selective mortality Labor market differentials Migration Limitations Non-experimental data Cannot rule out role of cohort- and district-specific characteristics

Follow up work Other Tanzania possibilities Experimental interventions: e.g. IPTi in southern Tanzania Quasi-experiments: Zanzibar eradication More phase-in models: U5CC phase in, exploit district-level TNVS data, work with DSS research teams? Kenya’s universal coverage campaign Uganda?

conclusions Preliminary conclusions Preliminary evidence of substantial effect size (0.1-0.2 st deviations) Further evidence for ITN distribution, early childhood health interventions more broadly Implications for cost effectiveness of ITN distribution Value of large sample surveys for non-experimental program evaluation