Targeting Using Differential Incentives: Evidence from a Field Experiment

In a field experiment in Nepal, we varied the amount of financial incentives provided to health outreach workers by the ethnicity of the client they recruited for a free sugar level assessment. We find that our differential incentive in the ratio of 2.5∶1, geared toward encouraging a disadvantaged referral, raises the chances of such a referral by 11.6 percentage points (95% confidence interval, 1.1–22.1). This effect translates to an incentive elasticity of referral of 0.2. There is no evidence that the outreach workers refer less sick individuals to benefit from higher financial incentives; nor do they target fewer overall referrals

Essays in Health Economics

My dissertation broadly relates to the low uptake of preventive health services in developing countries despite the services’ low cost and potential to avert subsequent catastrophic expenses. In the first two chapters, I answer two key questions on preventive health that are of general interest to health researchers and policymakers. First, can we improve the uptake of health services by the traditionally marginalized groups through the use of differential financial incentives to outreach workers? I answer the question using a field experiment in Nepal. In the experiment, I varied the amount of financial incentives provided to the health outreach workers by the ethnicity of the client they recruited for a free sugar-level assessment. I also varied the amount of incentives the clients received for appearing for the assessment. I find that the barriers due to ethnicity are high. Even a highly skewed differential incentive (in the ratio of 5:2) favoring cross-ethnic interactions is insufficient to offset the barriers. Encouragingly, differential incentives to the advantaged workers, geared toward encouraging them to refer disadvantaged individuals, have the potential to improve access for the disadvantaged groups. Second, what are the long-term consequences of preventive health measures undertaken in childhood? There is now a critical threshold of evidence documenting the relationship between one’s exposure to shocks in early life and outcomes in adulthood. However, there is limited evidence on pathways and mechanisms and the role of critical periods. In the second chapter, I attempt to fill this gap by evaluating the long-term effects of Nepal’s vitamin A supplementation program. The primary goal of the program was to reduce mortality associated with the nutrient’s deficiency. The sequential rollout of the program between 1993 and 2001 and the age eligibility provide an exogenous variation in exposure to the program. Utilizing that variation, I find that the program reduced the probability of having a disability or blindness, kept children in school longer, and enabled them to complete different grades by an expected age. The positive effects on disability and education seem to have improved marriage prospects. The program also had different effects on individuals based on their timing of the exposure to the program, with a longer exposure usually strengthening the positive effects. As expected, effects also differed by the individual’s gender and ethnicity, with more pronounced effects for men and individuals from traditionally advantaged ethnic groups. In the third chapter, I evaluate an existing program broadly aimed at reducing child mortality and improving women’s health behavior using a rigorous econometric technique. I evaluate the impact of Community-Based Neonatal Care Package, which Nepal’s government piloted in 2009 in 10 of the 75 districts. The causal effect of the program is established using a before-and-after comparison of outcomes in program districts relative to those in non-program districts. I find that the program was successful in encouraging cleaner deliveries for births that took place at home and in increasing prenatal visits to the health center by pregnant women significantly. Despite these positive effects on intermediate outcomes, the program’s overall effect on neonatal mortality was limited. There is also no evidence that the program increased institutional or professional-attended deliveries. The lack of an effect on other supply-dependent indicators suggests that supply-side constraints may have dampened the program’s overall effect.PHDHealth Services Organization & PolicyUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttps://deepblue.lib.umich.edu/bitstream/2027.42/138604/1/yubraj_1.pd

Child‐level double burden of malnutrition in the MENA and LAC regions: Prevalence and social determinants

Although the prevalence of obesity has rapidly increased in the low‐ and middle‐income countries of the Middle East and North Africa (MENA) and Latin America and the Caribbean (LAC) regions, child undernutrition remains a public‐health challenge. We examined region‐specific sociodemographic determinants of this double burden of malnutrition, specifically, the co‐occurrence of child stunting and overweight, using Demographic and Health Survey and Multiple Indicator Cluster Survey data (2003–2016) from 11 countries in the MENA (n = 118,585) and 13 countries in the LAC (n = 77,824) regions. We used multiple logistic regressions to model region‐specific associations of maternal education and household wealth with child nutritional outcomes (6–59 months). The prevalence of stunting, overweight, and their co‐occurrence was 24%, 10%, and 4.3% in children in the MENA region, respectively, and 19%, 5%, and 0.5% in children in the LAC region, respectively. In both regions, higher maternal education and household wealth were significantly associated with lower odds of stunting and higher odds of overweight. As compared with the poorest wealth quintiles, decreased odds of co‐occurring stunting and overweight were observed among children from the second, third, and fourth wealth quintiles in the LAC region. In the MENA region, this association was only statistically significant for the second wealth quintile. In both regions, double burden was not statistically significantly associated with maternal education. The social patterning of co‐occurring stunting and overweight in children varied across the two regions, indicating potential differences in the underlying aetiology of the double burden across regions and stages of the nutrition transition.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/154671/1/mcn12923_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/154671/2/mcn12923.pd

Household migration and children’s diet in Nepal: an exploratory study

Abstract Objective Individuals from low-income countries often migrate abroad for employment. The association between such migration and investment in education as well as other societal and familial outcomes has previously been examined. However, we have a limited understanding of the association between migration and children’s nutrition. We aim to determine the extent to which migration of household members influences children’s diet in a semi-urban region of Nepal. Results In our study setting, children in households with a migrant had higher dietary diversity scores, 0.69 on average, than their counterparts in households without a migrant. These children were approximately 43% points more likely to meet a minimum requirement for dietary diversity. These differences originated primarily from higher consumption of meat (41% points) and eggs (20% points). Approximately 37 percent of children in the sample consumed processed food during the 24 h preceding the survey. However, we found no evidence that migration was associated with the consumption of processed foods or with reduced frequency of breastfeeding. Our finding that migration is associated with higher consumption of meat and eggs is particularly encouraging, given that the protein deficiency in Nepal is estimated to be nearly 43 percent.https://deepblue.lib.umich.edu/bitstream/2027.42/152156/1/13104_2019_Article_4430.pd

Protocol for a randomized controlled trial on community education and surveillance on antibiotics use among young children in Nepal

BACKGROUND: Antimicrobial resistance (AMR) is one of the top ten threats to global health. There exists limited empirical evidence on effective approaches to address this threat. In low- and middle-income countries (LMICs), one of the primary drivers of AMR is easy access to antibiotics without prescriptions, in particular from community pharmacies. Interventions to reduce non-prescribed use of antibiotics and surveillance systems to track such usage are critically needed. This protocol describes a study that aims to test the effect of an educational intervention targeted to parents of young children on non-prescribed antibiotics consumption in Nepal and to track such consumption using a phone-based application. METHODS: The study is a clustered randomized controlled trial, in which we randomly assign 40 urban wards of Kathmandu Valley to either treatment group or control group, and randomly select 24 households in each ward. Households in the treatment group will receive an education intervention consisting of an AMR pitch (an in-person interaction that lasts up to an hour) by community nurses, videos and text messages on AMR every two weeks, and a brochure. We will conduct a survey at baseline with the parents of children ages 6 months to 10 years and track consumption of antibiotics and health care use among these children for a period of 6 months using a phone-based application. CONCLUSION: While the study will primarily inform future policy and programmatic efforts to reduce AMR in Nepal, the study-both the education intervention and the surveillance system-can serve as a prototype for tackling AMR in other similar settings

Integrated management of neonatal and childhood illness strategy in Zimbabwe: An evaluation.

More than five million children under the age of five die each year worldwide, primarily from preventable and treatable causes. In response, the World Health Organization's Integrated Management of Childhood Illnesses (IMNCI) strategy has been adopted in more than 95 low- and middle-income countries, 41 of them from Africa. Despite IMNCI's widespread implementation, evidence on its impact on child mortality and institutional deliveries is limited. This study examined the effect of IMNCI strategy in the context of Zimbabwe, where neonatal and infant mortality rates are among the highest in the world. We used binary logistic regression to analyze cross-sectional data from the 2015 Zimbabwe Demographic and Health Survey. Zimbabwe implemented the IMNCI strategy in 2012. Our empirical strategy involved comparing neonatal and infant mortality and institutional deliveries within the same geographic area before and after IMNCI implementation in a nationally representative sample of children born between 2010 and 2015. Exposure to IMNCI was significantly associated with a reduction in neonatal mortality (adjusted odds ratio (95% CI): 0.70 (0.50, 0.98)) and infant mortality (adjusted odds ratio (95% CI): 0.69 (0.54, 0.91)). The strategy also helped increase institutional deliveries significantly (adjusted odds ratio (95% CI): 1.95 (1.67, 2.28)). Further analyses revealed that these associations were concentrated among educated women and in rural areas.The IMNCI strategy in Zimbabwe seems to be successful in delivering its intended goals. Future programmatic and policy efforts should target women with low education and those residing in urban areas. Furthermore, sustaining the positive impact and achieving the child health-related Sustainable Development Goals will require continued political will in raising domestic financial investments to ensure the sustainability of maternal and child health programs

Evidence on result-based financing in maternal and child health in low- and middle-income countries : a systematic review

Introduction: Result-Based Financing (RBF) is an umbrella term for financial mechanisms that link incentives to outputs or outcomes. International development agencies are promoting RBF as a viable financing approach for the realization of universal health coverage, with numerous pilot trials, particularly in low- and middle-income countries (LMICs). There is limited synthesized evidence on the performance of these mechanisms and the reasons for the lack of RBF institutionalization. This study aims to review the evidence of RBF schemes that have been scaled or institutionalized at a national level, focusing on maternal, newborn, and child health (MNCH) programming in LMICs. Methods: A systematic literature review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The authors identified and reviewed country-level RBF evaluation reports for the period between January 2000 and June 2019. Data were extracted from both published and gray literature on RBF application in MNCH using a predesigned matrix. The matrix headers included country of application; program setting; coverage and duration; evaluation design and methods; outcome measures; and key findings. A content thematic analysis approach was used to synthesize the evidence and emerging issues. Results: The review identified 13 reports from 11 countries, predominantly from Sub-Saharan Africa. Performance-based financing was the most common form of RBF initiatives. The majority of evaluation designs were randomized trials. The evaluations focused on outputs, such as coverage and service utilization, rather than outcomes. RBF schemes in all 11 countries expanded their scope, either geographically or accordingly in terms of performance indicators. Furthermore, only three studies conducted a cost-effectiveness analysis, and only two included a discussion on RBF's sustainability. Only three countries have institutionalized RBF into their national policy. On the basis of the experience of these three countries, the common enabling factors for institutionalization seem to be political will, domestic fund mobilization, and the incorporation of demand-side RBF tools. Conclusion: RBF evidence is still growing, partial, and inconclusive. This limited evidence may be one of the reasons why many countries are reluctant to institutionalize RBF. Additional research is needed, particularly regarding cost-effectiveness, affordability, and sustainability of RBF programs