1. Learning from research to improve health delivery: case of Sierra Leone Rachel Glennerster (IGC Lead Academic for Sierra Leone and JPAL)

2. Health delivery challenge in Africa Simple highly cost-effective prevention with low takeup Poor will spend on acute care, not prevention Underinvestment in health world wide phenomena Research suggests often procrastination not hostility Making prevention cheap (free) and convenient, substantially increases take up and is cost-effective Kremer and Glennerster (2011) But, with highly disbursed populations how do you provide convenient quality health care? How do you monitor disbursed staff?

3. Access to clinics over time, Sierra Leone Source: National Public Services Survey 2011, DecSec

4. Lessons from post war recovery

5. Lessons from research suggest way forward Its cheaper to incentivize patients to come to clinics than to build more clinics or send health staff hamlet to hamlet (Banerjee, Duflo, Glennerster, and Kothari, 2010) Many of the programs designed to improve provider accountability have proved unsuccessful, absenteeism increases with qualifications (Kremer and Glennerster, 2010) More, but less qualified, staff to give simple prevention technologies Intuitive but not yet rig evidence to support this Recruiting the right people more important than monitoring (Ashraf, Bandiera, and Scott) Community report cards can help monitor disbursed health workers and improve health (Bonargent, Dube, Haushofer, Siddiqi, 2015)

6. Nudge incentives to increase immunization

7. Improving provider accountability is hard 7 Cost per additional day of provider attendance

8. Community monitoring: birth in a clinic

9. Community monitoring: illegal fees

10. Community monitoring: children wasted

11. CM: communities helping nurse with garden

12. Taking lessons from one context to another Is one rigorous evaluation of immunization incentives enough evidence for Sierra Leone government to act? Tested in India with an NGO Want to scale it up in Sierra Leone with government Incentives for immunization Higher completed vaccination rate Much more evidence this type of approach is likely to work Lots of practical issues to work through context specific

13. What is needed for incentives to work? Parents want to vaccinate Can access clinic Provider presence sufficient Parents pro- crastinate Incentives given to parents Evidence on behavioral Do basic conditions hold locally? Local logistics critical Impact Incentives delivered to clinic Small incentives offset bias Immuniza- tion rises Health improves

14. How do we incorporate these lessons? Basic conditions appropriate for incentives for immunization Need to attract patients back to clinics post Ebola PreEbola high rates for early vaccines but drop off Special campaigns to boost rates are expensive What incentive to use? What supply chain to use for delivery? How to avoid incentive being siphoned off and sold? Community Health Workers offer promise of delivering prevention cheaply and conveniently but many questions Can SL attract the high quality CHWs Zambia did? How to reward them—incorporate into performance based pay? Can Community Monitoring be incorporated in a cheap and efficient way? 14

15. International Growth Centre London School of Economics and Political Science Houghton Street London WC2 2AE www.theigc.org