[show abstract][hide abstract] ABSTRACT: The Affordable Medicines Facility - malaria (AMFm), implemented at national scale in eight African countries or territories, subsidized quality-assured artemisinin combination therapy (ACT) and included communication campaigns to support implementation and promote appropriate anti-malarial use. This paper reports private for-profit provider awareness of key features of the AMFm programme, and changes in provider knowledge of appropriate malaria treatment.
This study had a non-experimental design based on nationally representative surveys of outlets stocking anti-malarials before (2009/10) and after (2011) the AMFm roll-out.
Based on data from over 19,500 outlets, results show that in four of eight settings, where communication campaigns were implemented for 5-9 months, 76%-94% awareness of the AMFm 'green leaf' logo, 57%-74% awareness of the ACT subsidy programme, and 52%-80% awareness of the correct recommended retail price (RRP) of subsidized ACT were recorded. However, in the remaining four settings where communication campaigns were implemented for three months or less, levels were substantially lower. In six of eight settings, increases of at least 10 percentage points in private for-profit providers' knowledge of the correct first-line treatment for uncomplicated malaria were seen; and in three of these the levels of knowledge achieved at endline were over 80%.
The results support the interpretation that, in addition to the availability of subsidized ACT, the intensity of communication campaigns may have contributed to the reported levels of AMFm-related awareness and knowledge among private for-profit providers. Future subsidy programmes for anti-malarials or other treatments should similarly include communication activities.
[show abstract][hide abstract] ABSTRACT: As agents for their patients, providers often make treatment decisions on behalf of patients, and their choices can affect health outcomes. However, providers operate within a network of relationships and are agents not only for their patients, but also other health sector actors, such as their employer, the Ministry of Health, and pharmaceutical suppliers. Providers’ stated preferences for the treatment of uncomplicated malaria were examined to determine what factors predict their choice of treatment in the absence of information and institutional constraints, such as the stock of medicines or the patient’s ability to pay.
518 providers working at non-profit health facilities and for-profit pharmacies and drug stores in Yaoundé and Bamenda in Cameroon and in Enugu State in Nigeria were surveyed between July and December 2009 to elicit the antimalarial they prefer to supply for uncomplicated malaria. Multilevel modelling was used to determine the effect of financial and non-financial incentives on their preference, while controlling for information and institutional constraints, and accounting for the clustering of providers within facilities and geographic areas.
69% of providers stated a preference for artemisinin-combination therapy (ACT), which is the recommended treatment for uncomplicated malaria in Cameroon and Nigeria. A preference for ACT was significantly associated with working at a for-profit facility, reporting that patients prefer ACT, and working at facilities that obtain antimalarials from drug company representatives. Preferences were similar among colleagues within a facility, and among providers working in the same locality. Knowing the government recommends ACT was a significant predictor, though having access to clinical guidelines was not sufficient.
Providers are agents serving multiple principals and their preferences over alternative antimalarials were influenced by patients, drug company representatives, and other providers working at the same facility and in the local area. Efforts to disseminate drug policy should target the full range of actors involved in supplying drugs, including providers, employers, suppliers and local communities.
Social Science [?] Medicine 01/2014; · 2.73 Impact Factor
[show abstract][hide abstract] ABSTRACT: There is increased interest in using commercial providers for improving access to quality malaria treatment. Understanding their current role is an essential first step, notably in terms of the volume of diagnostics and anti-malarials they sell. Sales volume data can be used to measure the importance of different provider and product types, frequency of parasitological diagnosis and impact of interventions. Several methods for measuring sales volumes are available, yet all have methodological challenges and evidence is lacking on the comparability of different methods.
Using sales volume data on anti-malarials and rapid diagnostic tests (RDTs) for malaria collected through provider recall (RC) and retail audits (RA), this study measures the degree of agreement between the two methods at wholesale and retail commercial providers in Cambodia following the Bland-Altman approach. Relative strengths and weaknesses of the methods were also investigated through qualitative research with fieldworkers.
A total of 67 wholesalers and 107 retailers were sampled. Wholesale sales volumes were estimated through both methods for 62 anti-malarials and 23 RDTs and retail volumes for 113 anti-malarials and 33 RDTs. At wholesale outlets, RA estimates for anti-malarial sales were on average higher than RC estimates (mean difference of four adult equivalent treatment doses (95% CI 0.6-7.2)), equivalent to 30% of mean sales volumes. For RDTs at wholesalers, the between-method mean difference was not statistically significant (one test, 95% CI -6.0-4.0). At retail outlets, between-method differences for both anti-malarials and RDTs increased with larger volumes being measured, so mean differences were not a meaningful measure of agreement between the methods. Qualitative research revealed that in Cambodia where sales volumes are small, RC had key advantages: providers were perceived to remember more easily their sales volumes and find RC less invasive; fieldworkers found it more convenient; and it was cheaper to implement than RA.Discussion/conclusions: Both RA and RC had implementation challenges and were prone to data collection errors. Choice of empirical methods is likely to have important implications for data quality depending on the study context.
[show abstract][hide abstract] ABSTRACT: In low- and middle-income countries, government budgets are rarely sufficient to cover a public hospital's operating costs. Shortfalls are typically financed through a combination of health insurance contributions and user charges. The mixed nature of this financing arrangement potentially creates financial incentives to treat patients with equal health need unequally. Using data from the Philippines, the authors analyzed whether doctors respond to such incentives. After controlling for a patient's condition, they found that patients using insurance, paying more for hospital accommodation, and being treated in externally monitored hospitals were likely to receive more care. This highlights the worrying possibility that public hospital patients with equal health needs are not always equally treated.
Asia-Pacific Journal of Public Health 02/2013; · 1.06 Impact Factor
[show abstract][hide abstract] ABSTRACT: BACKGROUND: In recent years an increasing number of public investments and policy changes have been made to improve the availability, affordability and quality of medicines available to consumers in developing countries, including anti-malarials. It is important to monitor the extent to which these interventions are successful in achieving their aims using quantitative data on the supply side of the market. There are a number of challenges related to studying supply, including outlet sampling, gaining provider cooperation and collecting accurate data on medicines. This paper provides guidance on key steps to address these issues when conducting a medicine outlet survey in a developing country context. While the basic principles of good survey design and implementation are important for all surveys, there are a set of specific issues that should be considered when conducting a medicine outlet survey. METHODS: This paper draws on the authors' experience of designing and implementing outlet surveys, including the lessons learnt from ACTwatch outlet surveys on anti-malarial retail supply, and other key studies in the field. Key lessons and points of debate are distilled around the following areas: selecting a sample of outlets; techniques for collecting and analysing data on medicine availability, price and sales volumes; and methods for ensuring high quality data in general.Results and conclusions: The authors first consider the inclusion criteria for outlets, contrasting comprehensive versus more focused approaches. Methods for developing a reliable sampling frame of outlets are then presented, including use of existing lists, key informants and an outlet census. Specific issues in the collection of data on medicine prices and sales volumes are discussed; and approaches for generating comparable price and sales volume data across products using the adult equivalent treatment dose (AETD) are explored. The paper concludes with advice on practical considerations, including questionnaire design, field worker training, and data collection. Survey materials developed by ACTwatch for investigating anti-malarial markets in sub-Saharan Africa and Asia provide a helpful resource for future studies in this area.
[show abstract][hide abstract] ABSTRACT: We examine the impact of removing user fees for healthcare in rural Ghana using data from a randomized experiment that includes rich information on objective measures of child health status. We find that free care increased use of formal healthcare shifting care seeking away from informal providers, with particularly strong effects for children who were anaemic at baseline. There was no health effect on the intervention population taken overall. However, consistent with the utilization findings, there were health improvements among those with anaemia initially. Further benefits included a large reduction in health spending, with the effect greater at higher levels of the medical spending distribution. Free care was found to have no influence on a range of malaria prevention behaviours or on the incidence of self-reported illness, suggesting that ex-ante moral hazard is unlikely to be a concern in this particular setting. (JEL D12, I10, I18, I31)
Journal of Development Economics 01/2013; · 2.13 Impact Factor
[show abstract][hide abstract] ABSTRACT: BACKGROUND: The paper presents evidence about the distribution of the benefits of public expenditures on a subset of priority public health services that are supposed to be provided free of charge in the public sector, using the framework of benefit incidence analysis. METHODS: The study took place in 2 rural and 2 urban Local Government Areas from Enugu and Anambra states, southeast Nigeria. A questionnaire was used to collect data on use of the priority public health services by all individuals in the households (n=22,169). The level of use was disaggregated by socio-economic status (SES), rural-urban location and gender. Benefits were valued using the cost of providing the service. Net benefit incidence was calculated by subtracting payments made for services from the value of benefits. RESULTS: The results showed that 3,281 (14.8%) individuals consumed wholly free services. There was a greater consumption of most free services by rural dwellers, females and those from poorer SES quintiles (but not for insecticide-treated nets and ante-natal care services). High levels of payment were observed for immunisation services, insecticide-treated nets, anti-malarial medicines, antenatal care and childbirth services, all of which are supposed to be provided for free. The net benefits were significantly higher for the rural residents, males and the poor compared to the urban residents, females and better-off quintiles. CONCLUSION: It is concluded that coverage of all of these priority public health services fell well below target levels, but the poorer quintiles and rural residents that are in greater need received more benefits, although not so for females. Payments for services that are supposed to be delivered free of charge suggests that there may have been illegal payments which probably hindered access to the public health services.
International Journal for Equity in Health 11/2012; 11(1):70. · 1.71 Impact Factor
[show abstract][hide abstract] ABSTRACT: BACKGROUND: Malaria is one of the greatest causes of mortality worldwide. Use of the most effective treatments for malaria remains inadequate for those in need, and there is concern over the emergence of resistance to these treatments. In 2010, the Global Fund launched the Affordable Medicines Facility-malaria (AMFm), a series of national-scale pilot programmes designed to increase the access and use of quality-assured artemisinin based combination therapies (QAACTs) and reduce that of artemisinin monotherapies for treatment of malaria. AMFm involves manufacturer price negotiations, subsidies on the manufacturer price of each treatment purchased, and supporting interventions such as communications campaigns. We present findings on the effect of AMFm on QAACT price, availability, and market share, 6-15 months after the delivery of subsidised ACTs in Ghana, Kenya, Madagascar, Niger, Nigeria, Uganda, and Tanzania (including Zanzibar). METHODS: We did nationally representative baseline and endpoint surveys of public and private sector outlets that stock antimalarial treatments. QAACTs were identified on the basis of the Global Fund's quality assurance policy. Changes in availability, price, and market share were assessed against specified success benchmarks for 1 year of AMFm implementation. Key informant interviews and document reviews recorded contextual factors and the implementation process. FINDINGS: In all pilots except Niger and Madagascar, there were large increases in QAACT availability (25·8-51·9 percentage points), and market share (15·9-40·3 percentage points), driven mainly by changes in the private for-profit sector. Large falls in median price for QAACTs per adult equivalent dose were seen in the private for-profit sector in six pilots, ranging from US$1·28 to $4·82. The market share of oral artemisinin monotherapies decreased in Nigeria and Zanzibar, the two pilots where it was more than 5% at baseline. INTERPRETATION: Subsidies combined with supporting interventions can be effective in rapidly improving availability, price, and market share of QAACTs, particularly in the private for-profit sector. Decisions about the future of AMFm should also consider the effect on use in vulnerable populations, access to malaria diagnostics, and cost-effectiveness. FUNDING: The Global Fund to Fight AIDS, Tuberculosis and Malaria, and the Bill & Melinda Gates Foundation.
[show abstract][hide abstract] ABSTRACT: Neonatal mortality accounts for 43% of global under-five deaths and is decreasing more slowly than maternal or child mortality. Donor funding has increased for maternal, newborn, and child health (MNCH), but no analysis to date has disaggregated aid for newborns. We evaluated if and how aid flows for newborn care can be tracked, examined changes in the last decade, and considered methodological implications for tracking funding for specific population groups or diseases.
We critically reviewed and categorised previous analyses of aid to specific populations, diseases, or types of activities. We then developed and refined key terms related to newborn survival in seven languages and searched titles and descriptions of donor disbursement records in the Organisation for Economic Co-operation and Development's Creditor Reporting System database, 2002-2010. We compared results with the Countdown to 2015 database of aid for MNCH (2003-2008) and the search strategy used by the Institute for Health Metrics and Evaluation. Prior to 2005, key terms related to newborns were rare in disbursement records but their frequency increased markedly thereafter. Only two mentions were found of "stillbirth" and only nine references were found to "fetus" in any spelling variant or language. The total value of non-research disbursements mentioning any newborn search terms rose from US$38.4 million in 2002 to US$717.1 million in 2010 (constant 2010 US$). The value of non-research projects exclusively benefitting newborns fluctuated somewhat but remained low, at US$5.7 million in 2010. The United States and the United Nations Children's Fund (UNICEF) provided the largest value of non-research funding mentioning and exclusively benefitting newborns, respectively.
Donor attention to newborn survival has increased since 2002, but it appears unlikely that donor aid is commensurate with the 3.0 million newborn deaths and 2.7 million stillbirths each year. We recommend that those tracking funding for other specific population groups, diseases, or activities consider a key term search approach in the Creditor Reporting System along with a detailed review of their data, but that they develop their search terms and interpretations carefully, taking into account the limitations described. Please see later in the article for the Editors' Summary.
PLoS Medicine 10/2012; 9(10):e1001332. · 15.25 Impact Factor
[show abstract][hide abstract] ABSTRACT: BACKGROUND: The current target of universal access to long-lasting, insecticide-treated nets (LLIN) is 80% coverage to reduce malaria deaths by 75% by 2015. So far, campaigns have been the main channel for large-scale delivery of LLINs, however the World Health Organization has recommended that equal priority should be given to delivery via routine antenatal care (ANC) and immunization systems (EPI) to target pregnant women and children from birth. These various channels of LLIN delivery are targeted to children of different ages. Since risk of mortality varies with child age and LLIN effectiveness declines with net age, it was hypothesized that the age at which a child receives a new LLIN, and therefore the delivery channel, is important in optimizing the health impact of a net. METHODS: A simple dynamic mathematical model was developed of delivery and impact of LLINs among children under five years of age and their household members, incorporating data on age-specific malaria death rates, net use by household structure, and net efficacy over time. RESULTS: The presented analysis finds that supplementing a universal mass campaign with extra ANC delivery would achieve a 1.4 times higher mortality reduction than campaign delivery alone, reflecting that children born in the years between campaigns would otherwise have access to old nets or no nets at an age of high risk. The relative advantage of supplementary ANC delivery is still present though smaller if malaria transmission levels are lower or if there is a strong mass effect achieved by mass campaigns. CONCLUSION: These results indicate that LLIN delivery policies must take into account the age of greatest malaria risk. Emphasis should be placed on supporting routine delivery of LLINs to young children as well as campaigns. Lucy C Okell and Lucy Smith Paintain contributed equally.
[show abstract][hide abstract] ABSTRACT: The level of access to intermittent preventive treatment for malaria in pregnancy (IPTp) in Nigeria is still low despite relatively high antenatal care coverage in the study area. This paper presents information on provider factors that affect the delivery of IPTp in Nigeria.
Data were collected from heads of maternal health units of 28 public and six private health facilities offering antenatal care (ANC) services in two districts in Enugu State, south-east Nigeria. Provider knowledge of guidelines for IPTp was assessed with regard to four components: the drug used for IPTp, time of first dose administration, of second dose administration, and the strategy for sulphadoxine-pyrimethamine (SP) administration (directly observed treatment, DOT). Provider practices regarding IPTp and facility-related factors that may explain observations such as availability of SP and water were also examined.
Only five (14.7%) of all 34 providers had correct knowledge of all four recommendations for provision of IPTp. None of them was a private provider. DOT strategy was practiced in only one and six private and public providers respectively. Overall, 22 providers supplied women with SP in the facility and women were allowed to take it at home. The most common reason for doing so amongst public providers was that women were required to come for antenatal care on empty stomachs to enhance the validity of manual fundal height estimation. Two private providers did not think it was necessary to use the DOT strategy because they assumed that women would take their drugs at home. Availability of SP and water in the facility, and concerns about side effects were not considered impediments to delivery of IPTp.
There was low level of knowledge of the guidelines for implementation of IPTp by all providers, especially those in the private sector. This had negative effects such as non-practice of DOT strategy by most of the providers, which can lead to low levels of adherence to IPTp and ineffectiveness of IPTp. Capacity development and regular supportive supervisory visits by programme managers could help improve the provision of IPTp.
[show abstract][hide abstract] ABSTRACT: BACKGROUND: Recruitment and retention of health workers is a major concern. Policy initiatives emphasize financial incentives, despite mixed evidence of their effectiveness. Qualitative studies suggest that nurses especially may be more driven by altruistic motivations, but quantitative research has overlooked such values. This paper adds to the literature through characterizing the nature and determinants of nurses' altruism, based on a cross-country quantitative study. METHODS: An experimental 'dictator game' was undertaken with 1064 final year nursing students in Kenya, South Africa and Thailand between April 2007 and July 2008. This presents participants with a real financial endowment to split between themselves and another student, a patient or a poor person. Giving a greater share of this financial endowment to the other person is interpreted as reflecting greater altruism. RESULTS: Nursing students gave over 30% of their initial endowment to others (compared with 10% in similar experiments undertaken in other samples). Respondents in all three countries showed greater generosity to patients and the poor than to fellow students. CONCLUSIONS: Consideration needs to be given to how to appeal to altruistic values as an alternative strategy to encourage nurses to enter the profession and remain, such as designing recruitment strategies to increase recruitment of altruistic individuals who are more likely to remain in the profession.
Journal of Public Health 08/2012; · 2.06 Impact Factor
[show abstract][hide abstract] ABSTRACT: The intermittent screening and treatment (IST) of school children for malaria is one possible intervention strategy that could help reduce the burden of malaria among school children. Future implementation of IST will not only depend on its efficacy and cost-effectiveness but also on its acceptability to parents of the children who receive IST, as well as those responsible for its delivery. This study was conducted alongside a cluster-randomized trial to investigate local perceptions of school-based IST among parents and other stakeholders on the Kenyan south coast.
Six out of the 51 schools receiving the IST intervention were purposively sampled, based on the prevalence of Plasmodium infection, to participate in the qualitative study. Twenty-two focus group discussions and 17 in-depth interviews were conducted with parents and other key stakeholders involved in the implementation of school health programmes in the district. Data analysis was guided by the framework analysis method.
High knowledge of the burden of clinical malaria on school children, the perceived benefits of preventing clinical disease through IST and previous positive experiences and interactions with other school health programmes facilitated the acceptability of IST. However, lack of understanding of the consequences of asymptomatic parasitaemia for apparently healthy school children could potentially contribute to non-adherence to treatment, and use of alternative anti-malarial drugs with simpler regimens was generally preferred. The general consensus of stakeholders was that health workers were best placed to undertake the screening and provide treatment, and although teachers' involvement in the programme is critical, most participants were opposed to teachers taking finger-prick blood samples from children. There was also a strong demand for the distribution of mosquito nets to augment IST.
School-based malaria control through IST was acceptable to most parents and other stakeholders, but careful consideration of the various roles of teachers, community health workers, and health workers, and the use of anti-malarial drugs with simpler regimens are critical to its future implementation.
[show abstract][hide abstract] ABSTRACT: Nigeria instituted intermittent preventive treatment for malaria (IPTp) using sulphadoxine-pyrimethamine (SP) for pregnant women in 2001, but coverage remains low. This study examined the influence of demand side factors on IPTp coverage.
Data were collected using a household survey from 1307 women who were delivered of a live baby within the one-year period preceding the study and through an exit poll from 146 women attending antenatal clinics (ANC). Data analysis examined coverage based on the national and WHO guidelines for IPTp delivery which differ with regards to use of IPTp in the last month of pregnancy. Focus group discussions (FGDs) were undertaken to further explain demand side constraints to coverage.
From the household survey, 96.1% of respondents attended ANC, with most having five or more visits. Overall IPTp coverage for the first and second doses was 13.7% and 7.3% respectively. The coverage was higher in the urban areas compared to rural areas (p < 0.01). Amongst women who could have received IPTp based on the timing of their attendance, only 14.1% and 14.3% were offered the first dose based on national and WHO guidelines, while 7.7% and 7.5% were offered the second dose respectively giving significant missed opportunities. Amongst ANC attendees offered first and second doses, 98.9% and 96.9% respectively took the medicine. Only 13.6% and 21.5% of these clients reported taking the drug under direct observation. The low level of coverage was confirmed by exit survey data, which found coverage of 11.6% and 3.0% for the first and second doses. The FGDs revealed that women do not have many concerns about side effects, but they take drugs providers give them because they believe such drugs must be safe.
This study found low coverage of IPTp and high levels of missed opportunities supporting findings that high ANC attendance does not guarantee high IPTp coverage. Demand side factors such as ANC attendance, appropriate timing of attendance, and perceptions about side effects were not constraining factors to increased coverage, raising the need to examine supply side factors.
[show abstract][hide abstract] ABSTRACT: The extent to which removing user fees for health care in developing countries improves population health rests, in part, on how behavioural responses vary across individuals with different health needs. Using data from a randomised experiment of free care in Ghana and a measure of baseline health that is both objective and broad-based, we examined differential effects for initially ill and healthy children. We find that free care improved health seeking behaviour, lowered out-of-pocket spending and reduced anaemia amongst children who were ill at baseline but had no effect on initially healthy children. Whilst there was no health effect on the intervention population taken overall, the evidence suggests that removing user fees may have enabled individuals with the greatest health need to take up primary health care, thereby improving their health. There was no indication that free care encouraged frivolous use of services.
[show abstract][hide abstract] ABSTRACT: There is limited evidence about levels of socio-economic and other differences in catastrophic health spending in Nigeria and in many sub-Saharan African countries. The study estimated the level of catastrophic healthcare expenditures for different healthcare services and facilities and their distribution across socioeconomic status (SES) groups.
The study took place in four Local Government Areas in southeast Nigeria. Data were collected using interviewer-administered questionnaires administered to 4873 households. Catastrophic health expenditures (CHE) were measured using a threshold of 40% of monthly non-food expenditure. We examined both total monthly health expenditure and disaggregated expenditure by source and type of care.
The average total household health expenditure per month was 2354 Naira ($19.6). For outpatient services, average monthly expenditure was 1809 Naira ($15.1), whilst for inpatient services it was 610 Naira ($5.1). Higher health expenditures were incurred by urban residents and the better-off SES groups. Overall, 27% of households incurred CHE, higher for poorer socioeconomic groups and for rural residents. Only 1.0% of households had a member that was enrolled in a health insurance scheme.
The worse-off households (the poorest SES and rural dwellers) experienced the highest burden of health expenditure. There was almost a complete lack of financial risk protection. Health reform mechanisms are needed to ensure universal coverage with financial risk protection mechanisms.
PLoS ONE 01/2012; 7(7):e40811. · 3.73 Impact Factor
[show abstract][hide abstract] ABSTRACT: There is need for new information about the socio-economic and geographic differences in health seeking and expenditures on many health conditions, so to help to design interventions that will reduce inequity in utilisation of healthcare services and ensure universal coverage.
The paper contributes additional knowledge about health seeking and economic burden of different health conditions. It also shows the level of healthcare payments in public and private sector and their distribution across socioeconomic and geographic population groups.
A questionnaire was used to collect data from randomly selected householders from 4,873 households (2,483 urban and 2,390 rural) in southeast Nigeria. Data was collected on: health problems that people had and sought care for; type of care sought, outpatient department (OPD) visits and inpatient department (IPD) stays; providers visited; expenditures; and preferences for improving access to care. Data was disaggregated by socio-economic status (SES) and geographic location (urban versus rural) of the households.
Malaria and hypertension were the major communicable and non-communicable diseases respectively that required OPD and IPD. Patent medicine dealers (PMDs) were the most commonly used providers (41.1%), followed by private hospitals (19.7%) and pharmacies (16.4%). The rural dwellers and poorer SES groups mostly used low-level and informal providers. The average monthly treatment expenditure in urban area was 2444 Naira (US$20.4) and 2267 Naira (US$18.9) in the rural area. Higher SES groups and urbanites incurred higher health expenditures. People that needed healthcare services did not seek care mostly because the health condition was not serious enough or they could not afford the cost of services.
There were inequities in use of the different providers, and also in expenditures on treatment. Reforms should aim to decrease barriers to access to public and formal health services and also identify constraints which impede the equitable distribution and access of public health services for the general population especially for poor people and rural dwellers.
International Journal for Equity in Health 11/2011; 10(1):50. · 1.71 Impact Factor
[show abstract][hide abstract] ABSTRACT: Financial incentives are increasingly being advocated as an effective means to influence health-related behaviours. There is, however, limited evidence on whether they work in low-income countries, particularly when implemented at scale. This paper explores the impact of a national programme in Nepal that provides cash incentives to women conditional on them giving birth in a health facility. Using propensity score matching methods, we find that the programme had a positive, albeit modest, effect on the utilisation of maternity services. Women who had heard of the SDIP before childbirth were 4.2 percentage points (17 percent) more likely to deliver with a skilled attendant. The treatment effect is positively associated with the size of the financial package offered by the programme and the quality of care in facilities. Despite the positive effect on those exposed to the SDIP, low coverage of the programme suggests that few women actually benefited in the first few years.
Journal of Health Economics 11/2011; 31(1):271-84. · 1.60 Impact Factor