1 Challenges for m-Health: Improving Health Care Delivery Rachel Glennerster Abdul Latif Jameel Poverty Action Lab at MIT povertyactionlab.org

2 Two part challenge of health care delivery

3 Patients behavior Health behavior around the world appears irrational –It is not consistent with a model where patients invest in treatment or prevention until benefits and costs are equal But consistent ways in which people deviate from this model –Poor spend a lot of money on health –Most on acute care, little on long term care or prevention –Demand is very sensitive to price –Demand is very sensitive to distance Lack of money and knowledge are constraints but on their own do not fully explain health behavior Not just an issue for poor, in rich countries people do not: –Complete their courses of antibiotics, –Take iron pills –Wash hands

4 The health worker problem Absence Rates Bangladesh Ecuador India Indonesia Peru Uganda Bangladesh India Indonesia Peru Uganda

5 What works? Patient behavior –Reduced cost –Upfront incentives –Deadlines –Convenience Health worker behavior –Incentives tied to objective monitoring –Supervisor discretion on rewards undermines system –Contracting out entire systemneeds monitoring

6 Implications: health worker reliability Challenge is reliable, objective monitoring Cell phones potential monitoring tool Important that it not just be a monitoring tool Objective monitoring allows incentives Testing can help calibrate incentives for reliability

7 Applying the Lessons: X out TB Increased compliance with TB drug regimes critical to health and preventing spread of MDRTB TB compliance classic example of patient and health worker problems failures –Benefits are a long way off, pain is now –DOTS relies on reminders by health works, often unreliable X out TB seeks to solve this by –Reminderphone rings to remind patient to take pill –Monitoringurine strips generate code if patient has been taking their meds) –Less reliance on workersmonitoring done by patient and phone –Deadlinepatient enters code by SMS before deadline –Up front incentivespatient receives free minutes if correct code entered before deadline Testing can calibrate size of incentives needed for compliance

References Ashraf, Nava, James Berry and Jesse M. Shapiro (2007). Can Higher Prices Stimulate Product Use? Evidence from a Field Experiment in Zambia, NBER Working Paper No Banerjee, Abhijit, Angus Deaton, and Esther Duflo (2004a). Health Care Delivery in Rural. Rajasthan, Economic and Political Weekly, 39(9): Bjorkman, Martina, and Jakob Svensson (2007). Power to the People: Evidence from a Randomized Field Experiment of a Community-Based Monitoring Project in Uganda, Community- Based Monitoring of Primary Health Care PCEPR Working Paper No Bloom, Erik et al. (2006). Contracting for Health: Evidence from Cambodia, Brookings Institution Report, July 20, Cohen, Jessica, and Pascaline Dupas (2007). Free Distribution vs. Cost-Sharing: Evidence from a Malaria-Prevention Field Experiment in Kenya, Brookings Institution Global Economy and Development Working Paper, no. 11. Di Mario S. et al. (2005). What is the effectiveness of antenatal care? (Supplement). World Health Organization Regional Office for Europe, Health Evidence Network report. Kremer, Michael, and Alaka Holla (2008). Pricing and Access: Lessons from Randomized Evaluation in Education and Health, MIMEO, Harvard University. Kremer, Michael, and Edward Miguel (2007). The Illusion of Sustainability, Quarterly Journal of Economics, 122(3): Thornton, Rebecca (2008). "The Demand for, and Impact of, Learning HIV Status," American Economic Review, 98(5): 1829–63.

9 Cutting absenteeism is hard Cost per additional day attended

10 Cutting absenteeism is hard Increase in attendance rates