Menno Pradhan’s research while affiliated with Amsterdam Institute for Global Health and Development and other places

The National Hospital Insurance Fund (NHIF) of Kenya was upgraded to improve access to healthcare for impoverished households, expand universal health coverage (UHC), and boost the uptake of essential reproductive, maternal, newborn and child health (RMNCH) services. However, premiums may be unaffordable for the poorest households. The Innovative Partnership for Universal Sustainable Healthcare (i-PUSH) program targets low-income women and their households to improve their access to and utilization of quality healthcare, including RMNCH services, by providing subsidized, mobile phone-based NHIF coverage in combination with enhanced, digital training of community health volunteers (CHVs) and upgrading of health facilities. This study evaluated whether expanded NHIF coverage increased the accessibility and utilization of quality basic RMNCH services in areas where i-PUSH was implemented using a longitudinal cluster randomized controlled trial in Kakamega, Kenya. A total of 24 pair-matched villages were randomly assigned either to the treatment or the control group. Within each village, 10 eligible households (i.e., with a woman aged 15-49 years who was either pregnant or with a child below 4 years) were randomly selected. The study applied a Difference-in-Difference methodology based on a pooled cross-sectional analysis of baseline, midline and endline data, with robustness checks based on balanced panels and ANCOVA methods. The analysis sample included 346 women, of whom 248 had had a live birth in the 3 years prior to any of the surveys, and 424 children aged 0-59 months. Improved NHIF coverage did not have a statistically significant impact on any of the RMNCH outcome indicators at midline nor endline. Uptake of RMNCH services, however, improved substantially in both control and treatment areas at endline compared to baseline. For instance, significant increases were observed in the number of antenatal care visits from baseline to midline (mean = 2.62 to 2.92) p < 0.01) and delivery with a skilled birth attendant from baseline to midline (mean = 0.91 to 0.97 (p < 0.01). Expanded NHIF coverage, providing enhanced access to RMNCH services of unlimited duration at both public and private facilities, did not result in an increased uptake of care, in a context where access to basic public RMNCH services was already widespread. However, the positive overall trend in RMNCH utilization indicators, in a period of constrained access due to the COVID-19 pandemic, suggests that the other components of the i-PUSH program may have been beneficial. Further research is needed to better understand how the provision of insurance, enhanced CHV training and improved healthcare quality interact to ensure pregnant women and young children can make full use of the continuum of care.

We evaluate the impact of a producer organization avocado contract farming intervention in Kenya that included (1) an agreement to sell to an avocado exporting company, (2) access to training, and (3) support to gain group‐level Global Good Agricultural Practices ( GLOBALG.A.P .) certification as main activities. Using a (nonexperimental) doubly robust difference‐in‐differences design with farm‐level panel data from 2015 and 2017, we show that farmers began selling to the contracted company, were recently trained and received the GLOBALG.A.P . certification. However, the intervention's uptake was less than perfect, especially concerning the procurement aspect of the contract, suggesting widespread side selling. In terms of outcomes, contract farming nevertheless significantly improved sales prices and reported quality, increased direct sales to companies, and led to more planted trees, but also increased total production costs. The effects are driven by the Hass avocado variety, which is in higher demand in export markets and the contracted avocado variety. No significant income and other welfare effects were found.

Cheating reduces the signaling value of examinations. It also shifts the focus of teachers and students away from learning. Combating widespread cheating is difficult as students, teachers, and bureaucrats all benefit from high reported grades. We evaluate the impact of computer-based testing (CBT), an at-scale policy implemented by the Indonesian government to reduce widespread cheating in the national examinations. Exploiting the phased roll-out of the program from 2015 to 2019, we find that test scores declined dramatically, by 0.5 standard deviations, after the introduction of CBT. Schools with response patterns that indicated cheating prior to CBT adoption experienced a steeper decline. The effect is similar between schools with and without access to a computer lab, indicating that the reduction in the opportunity to cheat is the main reason for the test score decline. In districts with high adoption of CBT, schools that still used paper-based exams cheated less and scored lower, indicating spillovers of CBT. The results highlight the potential role of technology in improving the effectiveness in efforts to overcome collusive behavior in the education sector.

Background: Epidemics can cause significant disruptions of essential health care services. This was evident in West-Africa during the 2014-2016 Ebola outbreak, raising concerns that COVID-19 would have similar devastating consequences for the continent. Indeed, official facility-based records show a reduction in health care visits after the onset of COVID-19 in Kenya. Our question is whether this observed reduction was caused by lower access to health care or by reduced incidence of communicable diseases resulting from reduced mobility and social contacts. Methods: We analysed monthly facility-based data from 2018 to 2020, and weekly health diaries data digitally collected by trained fieldworkers between February and November 2020 from 342 households, including 1974 individuals, in Kisumu and Kakamega Counties, Kenya. Diaries data was collected as part of an ongoing longitudinal study of a digital health insurance scheme (Kakamega), and universal health coverage implementation (Kisumu). We assessed the weekly incidence of self-reported medical symptoms, formal and informal health-seeking behaviour, and foregone care in the diaries and compared it with facility-based records. Linear probability regressions with household fixed-effects were performed to compare the weekly incidence of health outcomes before and after COVID-19. Results: Facility-based data showed a decrease in health care utilization for respiratory infections, enteric illnesses, and malaria, after start of COVID-19 measures in Kenya in March 2020. The weekly diaries confirmed this decrease in respiratory and enteric symptoms, and malaria / fever, mainly in the paediatric population. In terms of health care seeking behaviour, our diaries data find a temporary shift in consultations from health care centres to pharmacists / chemists / medicine vendors for a few weeks during the pandemic, but no increase in foregone care. According to the diaries, for adults the incidence of communicable diseases/symptoms rebounded after COVID-19 mobility restrictions were lifted, while for children the effects persisted. Conclusions: COVID-19-related containment measures in Western Kenya were accompanied by a decline in respiratory infections, enteric illnesses, and malaria / fever mainly in children. Data from a population-based survey and facility-based records aligned regarding this finding despite the temporary shift to non-facility-based consultations and confirmed that the drop in utilization of health care services was not due to decreased accessibility, but rather to a lower incidence of these infections.

Objective: This study evaluates how a subsidized, mobile phone-based health insurance program affected insurance uptake, healthcare utilization and health expenditures for low-income women and their family members in Western Kenya. The program, targeting pregnant women and mothers of children below age four, addressed both demand- and supply-side constraints, providing subsidies through mobile money and support in digital registration while upgrading selected facilities and digitally training community health workers. Methods: The research was based on a cluster-RCT conducted between 2019 and 2021 in 24 villages in Kakamega County. After a baseline survey, 240 households (more than 1,300 individuals) were interviewed every week during 18 months to collect detailed financial and health data while the program was rolled out in the treatment communities, moving to phone-based interviewing after the onset of COVID-19. Results: The intervention had a significant impact on individual insurance uptake of 65.8 percentage points (from a baseline control mean 18.9 percent). We find weak positive impacts on formal healthcare utilization, and substantial increases in financial coverage of medical costs and associated reductions in out-of-pocket expenditures, particularly for medicines. Results are strongest for women, young children and individuals living closest to the clinics. Dynamic analyses show that impacts become increasingly pronounced over time, suggesting that women may need some time to get used to the digital insurance scheme. Conclusion: The program not only reduced the costs of enrolment, but also eliminated other (administrative, logistical, trust) barriers. The introduction of the scheme by trusted local agents, the hands-on assistance with the digital registration procedures at women's homes, and support in retrieving the necessary documentation such as children's birth certificates, have likely all contributed to the high enrolment rates, thereby improving access to good-quality care. Digital insurance has the potential to substantially enhance universal health coverage and financial protection for poor households.

In this paper we evaluate the impact of road development on household welfare in rural Papua New Guinea (PNG) between 1996 and 2010, using two geocoded cross-sectional national household surveys and corresponding road maps. We make use of time-variation in road surface type and condition as recorded in PNG’s National Road Asset Management System, focusing on routes that connect rural households to urban areas. To tackle endogenous placement of road infrastructure programs, we employ a correlated random effects model that controls for the location-specific average road quality over the period of analysis. We also use a newly developed generalised quantile regression method to investigate whether road works favour the poor. Our estimates show that better roads to nearest towns lead to higher consumption levels and housing quality, and to less reliance on subsistence farming. The effects are stronger among poor and remote households

Health insurance enrollment in many Sub‐Saharan African countries is low, even with highly subsidized premiums and exemptions for vulnerable populations. One possible explanation is low service quality, which results in a low valuation of health insurance. Using a randomized control trial in 64 primary health care facilities in Ghana, this study assesses the impact of a community engagement intervention designed to improve the quality of healthcare and health insurance services on households living nearby the facilities. Although the intervention improved the medical‐technical quality of health services, our results show that households' subjective perceptions of the quality of healthcare and insurance services did not increase. Nevertheless, the likelihood of illness and concomitant healthcare utilization reduced, and especially households who were not insured at baseline were more likely to enroll in health insurance. The results show that solely increasing the technical quality of care is not sufficient to increase households' subjective assessments of healthcare quality. Still, improving technical quality can directly contribute to health outcomes and further increase health insurance coverage, especially among the previously uninsured.

Background Universal Health Coverage ensures access to quality health services for all, with no financial hardship when accessing the needed services. Nevertheless, access to quality health services is marred by substantial resource shortages creating service delivery gaps in low-and middle-income countries, including Kenya. The Innovative Partnership for Universal Sustainable Healthcare (i-PUSH) program, developed by AMREF Health Africa and PharmAccess Foundation (PAF), aims to empower low-income women of reproductive age and their families through innovative digital tools. This study aims to evaluate the impact of i-PUSH on maternal and child health care utilization, women’s health including their knowledge, behavior, and uptake of respective services, as well as women’s empowerment and financial protection. It also aims to evaluate the impact of the LEAP training tool on empowering and enhancing community health volunteers’ health literacy and to evaluate the impact of the M-TIBA health wallet on savings for health and health insurance uptake. Methods This is a study protocol for a cluster randomized controlled trial (RCT) study that uses a four-pronged approach—including year-long weekly financial and health diaries interviews, baseline and endline surveys, a qualitative study, and behavioral lab-in-the-field experiments—in Kakemega County, Kenya. In total, 240 households from 24 villages in Kakamega will be followed to capture their health, health knowledge, health-seeking behavior, health expenditures, and enrolment in health insurance over time. Half of the households live in villages randomly assigned to the treatment group where i-PUSH will be implemented after the baseline, while the other half of the households live in control village where i-PUSH will not be implemented until after the endline. The study protocol was reviewed and approved by the AMREF Ethical and Scientific Review Board. Research permits were obtained from the National Commission for Science, Technology and Innovation agency of Kenya. Discussion People in low-and middle-income countries often suffer from high out-of-pocket healthcare expenditures, which, in turn, impede access to quality health services. Saving for healthcare as well as enrolment in health insurance can improve access to healthcare by building capacities at all levels—individuals, families, and communities. Notably, i-PUSH fosters savings for health care through the mobile-phone based “health wallet,” it enhances enrolment in subsidized health insurance through the mobile platform—M-TIBA—developed by PAF, and it seeks to improve health knowledge and behavior through community health volunteers (CHVs) who are trained using the LEAP tool—AMREF’s mHealth platform. The findings will inform stakeholders to formulate better strategies to ensure access to Universal Health Coverage in general, and for a highly vulnerable segment of the population in particular, including low-income mothers and their children. Trial registration Registered with Protocol Registration and Results System (protocol ID: AfricanPHRC; trial ID: NCT04068571: AEARCTR-0006089; date: 29 August 2019) and The American Economic Association’s registry for randomized controlled trials (trial ID: AEARCTR-0006089; date: 26 June 2020).

We examine the relationship between schooling completed and mathematics learning from 2000 to 2014 by developing learning profiles for Indonesia. Using nearly-nationally representative survey data, we find a large gap between students’ ability and standards set by the national curriculum. Learning declined over 14 years, a loss of a fourth of a standard deviation. To put this loss in context, the average child in grade 7 in 2014 achieved the same numeracy mastry as the average child in grade 4 in 2000. The reduction in learning was widespread, affecting all subgroups. Junior and senior secondary enrollment increased over this timeframe, but this decline was not due to changes in student composition.