1. 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

2. 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?

3. Malaria control in Tanzania
: Pilot social marketing of insecticide treated bed nets in two districts.
: national scale up of social marketing (SMITN- SMARTNET and TNVS projects)
: 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

4. 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
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,
District level

6. 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 “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.

7. 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 year old cohort (born in ) 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

8. 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

9. 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
0.0876
0.0462
(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
***
(0.0005)
secondary school in village
0.1697***
(0.0367)
Has donor project
(0.0432)
Regional dummies no
yes
Additional controls
Observations
94186
65441
66659 r2
0.4817
0.4935
0.4927
0.4943

10. Post-pilot scale up
Based on success of KINET, social marketing scaled up nationally
SMITN/SMARTNET program:
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

11. 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
(0.0256)
(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

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

13. 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?

14. conclusions Preliminary conclusions
Preliminary evidence of substantial effect size ( 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