Learning from research to improve health delivery: case of Sierra Leone

Rachel Glennerster (IGC Lead Academic for Sierra Leone and JPAL)

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?

Access to clinics over time, Sierra Leone

Source: National Public Services Survey 2011, DecSec

Lessons from post war recovery

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)

Nudge incentives to increase immunization

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Improving provider accountability is hard

Cost per additional day of provider attendance

Community monitoring: birth in a clinic

Community monitoring: illegal fees

Community monitoring: children wasted

CM: communities helping nurse with garden

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

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

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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?

International Growth Centre

London School of Economics and

Political Science

Houghton Street

London WC2 2AE 

www.theigc.org