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Overview

Value for Money An input from the Abdul Latif Jameel Poverty Action Lab Kamilla Gumede, J-PAL Africa. Overview. J-PAL specialises in impact evaluations of social programmes that make use of a randomised counterfactual

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Overview

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  1. Value for Money An input from the Abdul LatifJameel Poverty Action LabKamilla Gumede, J-PAL Africa

  2. Overview • J-PAL specialises in impact evaluations of social programmes that make use of a randomised counterfactual • Because we can measure the real impact of programmes, we can also assess programme efficacy and compare cost effectiveness of different programme approaches and policies • Today, I will present two insights about value for money: • Pricing of health products: • Immunisation for health care products • User fees for bednets • Cross-subsidisation: • Provision of health care services through schools

  3. Pricing health products • Demand problem. Low demand for preventive health interventions • Only a quarter of women in India breastfed their children within an hour of birth and the average period of exclusive breastfeeding is 2 months (WHO recommends 6 months of exclusive breastfeeding) • Fraction of children receiving deworming medicine dropped from 78% to 59% when parents had to sign a form • Immunisation for childhood diseases is one of the most cost effective health interventions, yet only 2% of children in Udaipur are fully immunised • Unreliable service delivery may discourage usage • Very high price-elasticityfor preventive health services, both for positive prices and negative prices (something special about zero)

  4. Absence rates for Teachers and Health Workers(based on nationally representative random checks) Absence Rate % Healthworkers Teachers Uganda Bangladesh India Indonesia Peru Ecuador GDP per capita, $PPP, 2005, WDI

  5. Fixing supply or demand (?) • High rates of absenteeism in health clinics may explain low rate of immunisation: • SevaMandir teamed-up with the government to organiseimmunisation camps. Male nurses (on a motorcycle) collect vaccines from government facilities. They then hold an immunisation camp in the village. Monthly, always the same date. • Very regular (95% of the planned camps took place). Announced by a local health worker who also tried to sensitise women to the need of getting children immunised. • Incentives for immunisation: • In some immunisation camps, SevaMandir offered one kilogram of lentils to mothers who took their children to be immunised and a set of plates for completed immunisation. • A very small reward would not convince people who are strongly against immunisation.

  6. %-share who are fully immunised

  7. High price-elasticity and user fees • User fees are advocated to promote sustainability of health services and to help make sure that goods and services are not wasted. But user fees is a barrier to access. • Do fees screen out those who never intend to use the product, and target it to those who need it the most? • Or does charging simply screen out the poor? • Charging even very small user fees substantially reduces adoption. When a program in Kenya moved from free deworming in schools to charging an average of 30 cents per child, take-up fell from 75 to 19 percent. • Cost sharing does not concentrate adoption on those who need products most. Families with children under 5 are not more likely to buy water disinfectant; the anemic are not more likely to buy bednets; children with high parasitic worm loads are no more likely to purchase deworming pills.

  8. Positive prices discourage use: bednet

  9. Sustainability ?

  10. Cross-subsidisation • MDGs for education seek to get 100% participation in primary school, and gender equality in education participation generally • Worldwide, children enroll in primary education – but low attendance rates. • Many interventions have been tried and found to work: • Conditional cash transfers to poor families - through PROGRESA - in Mexico. Monthly cash payments are - in theory - conditional on school attendance and more. • Free uniforms. • Merit scholarship (for secondary education) in last years of primary education, intended to motivate school attendance. • Mass school-based deworming.

  11. Dollars per years of education

  12. Summary • Budget officials play critical role in promoting value for money, as example: • Shift away from curative to preventive health • User fees can help get services to poor people, but not for all products and services • Cross-subsidisation: health delivery through schools • Environment of evidence based decision-making • J-PAL ongoing research on deliveries in health facilities in Nigeria; incentives and monitoring for service providers; recruitment and retainment of community health workers in Zambia; supply-chains for health product in Uganda; and more • What are key policy questions that we need scientific evidence on?

  13. www.povertyactionlab.org J-PAL Africa Southern African Labour and Development Research Unit SALDRU University of Cape Town South Africa Tel: +27 21 650 5981 jpalafrica@povertyactionlab.org

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