Comprehensive study addresses how health workers in West Africa should best distribute subsidies

December 11, 2014

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Jon Robinson recently presenting his research earlier this fall at the Division of Social Sciences' Research Frontiers Day

Jonathan Robinson Associate Professor of Economics at UC Santa Cruz, along with researchers from Stanford University and Massachusetts Institute of Technology (MIT), conducted an innovative study in sub-Saharan Africa that explores how health subsidies are distributed.

The study addresses the pressing and urgent need to study distribution efforts. If child mortality rates are to decrease, it is crucial that the help subsidized aide programs provide to vulnerable populations are delivered in an efficient, fast and cost effective way.  

Robinson and his co-authors, Pascaline Dupas, Associate Professor of Economics Stanford University and Rebecca Dizon-Ross, Postdoctoral Fellow at Massachusetts Institute of Technology, note the popular belief that health workers are not administering subsidies effectively - if at all.  “There is widespread concern that poor governance and in particular limited accountability among health workers seriously undermines the effectiveness of such programs,” Robinson et al remark.

Prior research, most notably the World Bank report Missing in Action: Teacher and Health Worker Absence in Developing Countries, painted a pessimistic account of medical provider absenteeism in developing nations.

Noteworthy Facts

  • 80% of those eligible receive subsidies
  • Nurses spend almost 20 minutes with clients, compared to other contexts where health workers spend much less time with clients
  • Health subsidy programs are cost effective
  • Corruption is very low

That report (along with others) raised the concern that service providers such as healthcare workers and teachers are generally providing poor effort, such as not showing up for work. There are also stories about corruption, like health workers extorting their clients and demanding bribes for their services. Others are also apprehensive about subsidies going to those who do not qualify for them, thus taking away from the families that need it the most.

So how are health agencies implementing their services? Are these concerns as widespread as we are meant to believe? Are workers held accountable? To answer these urgent questions, Robinson and co-authors worked with research teams to perform extensive audits over a six-month period on a World Health Organization approved antimalarial bed net distribution scheme at almost 200 health clinics across Ghana, Kenya and Uganda. 

Workers are motivated - one antimalarial net at a time

Robinson and his coauthors found that the picture is as not as bleak as it may seem. “This study finds much less severe agency problems than is commonly believed among practitioners and international agencies,” the report states.

It goes on to say how health workers “have higher levels of intrinsic job motivation, and feel more accountable. [...] We find positive correlations between these traits are performance levels.”

Voucher schemes don’t work: reduces health worker motivation and awareness

What the researchers found to be the less effective distribution method were voucher driven efforts, where clients are given a coupon they can redeem at external vendors. “Voucher schemes which are popular as a way to reduce health workers’ discretion and which have been implemented in a number of countries (most notably in Tanzania), appear to reduce program effectiveness: they make the program less visible and therefore reduce demand, and also appear to dampen health workers’ intrinsic motivation (especially if perceived as an anti-corruption measure)."

The researchers found that voucher programs can reduce visibility and awareness of a subsidy program. A voucher can easily be folded and put in a pocket when a mosquito net cannot. “Lower awareness could explain the lower coverage rate observed among the eligible: unaware women are unlikely to request a voucher if the health worker does not offer them one.”

Robinson and his coauthors also discovered that when health workers were involved in a voucher scheme, they felt untrusted. Thus, job morale and motivation was lower. This points to a potential problem: if pessimistic portrayals and mistrust of health care workers continue to be perpetuated - negative behaviors could unfold.

A copy of the full report, Governance and the Effectiveness of Public Health Subsidies, is available for download here.

Jonathan Robinson, Associate Professor of Economics at UC Santa Cruz co-authored the paper Governance and the Effectiveness of Public Health Subsidies with Pascaline Dupas, Associate Professor of Economics Stanford University and Rebecca Dizon-Ross, Postdoctoral Fellow at Massachusetts Institute of Technology. The study’s methodology mirrored the same research practices to the studies it dispels.

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